{
"Npi": {
"NPI": "1497563936",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "CLARK",
"FirstName": "BERNICE",
"MiddleName": "MONIQUE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "APRN",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1133 OBRIEN ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SOUTH BEND",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "46628-2541",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "574-217-6906",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "60205 BODNAR BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MISHAWAKA",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "46544-9342",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "574-325-5961",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/30/2024",
"LastUpdateDate": "07/29/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "163WP0808X",
"TaxonomyName": "Psychiatric/Mental Health Registered Nurse",
"LicenseNumber": "71016172A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LP0808X",
"TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
"LicenseNumber": "71016172A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}