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General NPI Number Information
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NPI Number | 1184387672
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Entity Type | Individual
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Provider Name | BEVERLY W CLARK FNP-C
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Gender | Female
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Dates
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Enumeration Date | 10/21/2021
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Last Update Date | 01/20/2022
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Provider Practice Location Address
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Address Line | 78 HOSPITAL RD
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City | MACON
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State | MS
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Zip | 39341-2490
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Country | US
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Telephone | 662-361-8338
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Fax |
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Provider Business Mailing Address
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Address Line | 4735 HIGHWAY 490 RD
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City | MACON
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State | MS
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Zip | 39341-9366
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Country | US
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Telephone | 662-361-8338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 904987
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License Number State | MS
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