Healthcare Provider Details

I. General information

NPI: 1558842930
Provider Name (Legal Business Name): ERICKA CLARK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CRAIN HWY S STE 301
GLEN BURNIE MD
21061-6446
US

IV. Provider business mailing address

1600 CRAIN HWY S STE 301
GLEN BURNIE MD
21061-6446
US

V. Phone/Fax

Practice location:
  • Phone: 410-787-8315
  • Fax:
Mailing address:
  • Phone: 410-787-8315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC005986
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11017507
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: