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General NPI Number Information
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NPI Number | 1548893506
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Entity Type | Individual
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Provider Name | THERESA ANN CLARK FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 02/18/2020
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Last Update Date | 12/12/2025
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Provider Practice Location Address
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Address Line | 22818 OLD US 20
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City | ELKHART
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State | IN
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Zip | 46516-9150
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Country | US
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Telephone | 574-389-1231
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Fax |
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Provider Business Mailing Address
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Address Line | 69014 TAMARACK RD
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City | WALKERTON
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State | IN
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Zip | 46574-9735
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Country | US
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Telephone |
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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 | 71010178A
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License Number State | IN
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