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General NPI Number Information
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NPI Number | 1871729889
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Entity Type | Individual
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Provider Name | MYRLITA SHAWN CLARK NP,C
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Gender | Female
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Dates
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Enumeration Date | 06/04/2009
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Last Update Date | 04/19/2016
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Provider Practice Location Address
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Address Line | 1999 W HUNTING PARK AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19140-2828
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Country | US
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Telephone | 215-228-9300
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Fax | 215-228-9913
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Provider Business Mailing Address
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Address Line | 432 N 6TH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19123-4004
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Country | US
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Telephone | 215-925-2400
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Fax | 215-925-9162
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | SPO10333
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License Number State | PA
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