Healthcare Provider Details

I. General information

NPI: 1225666035
Provider Name (Legal Business Name): AMANDA LOUISE CLARK RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 11/01/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 SAVAGE RD
CHARLESTON SC
29407-4726
US

IV. Provider business mailing address

PO BOX 23321
NEW YORK NY
10087-4321
US

V. Phone/Fax

Practice location:
  • Phone: 843-766-6308
  • Fax:
Mailing address:
  • Phone: 614-632-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26661
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number246707
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: