Healthcare Provider Details

I. General information

NPI: 1417811811
Provider Name (Legal Business Name): STEPHANIE CLARK CDCES, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 CYPRESS RD
FLORENCE SC
29505-6817
US

IV. Provider business mailing address

2105 CYPRESS RD
FLORENCE SC
29505-6817
US

V. Phone/Fax

Practice location:
  • Phone: 843-618-1219
  • Fax:
Mailing address:
  • Phone: 843-618-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number32100652
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: