Healthcare Provider Details

I. General information

NPI: 1366945214
Provider Name (Legal Business Name): VICTORIA CLARKE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W ATLANTIC AVE
HADDON HEIGHTS NJ
08035-1715
US

IV. Provider business mailing address

120 WHITE HORSE PIKE STE 112
HADDON HEIGHTS NJ
08035-1938
US

V. Phone/Fax

Practice location:
  • Phone: 856-546-3003
  • Fax: 856-547-5337
Mailing address:
  • Phone: 856-547-0539
  • Fax: 856-796-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberPENDING
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: