Healthcare Provider Details

I. General information

NPI: 1760471684
Provider Name (Legal Business Name): MARY ELIZABETH BERNAL CLARK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7536
  • Fax: 410-543-7272
Mailing address:
  • Phone: 410-543-7536
  • Fax: 410-543-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR131285
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: