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General NPI Number Information
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NPI Number | 1962954305
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Entity Type | Individual
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Provider Name | TERRI JO CLARK FNP-BC, MSN
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Gender | Female
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Dates
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Enumeration Date | 11/02/2016
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Last Update Date | 12/27/2023
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Provider Practice Location Address
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Address Line | 8550 NE 138TH LN BLDG 600
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City | LADY LAKE
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State | FL
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Zip | 32159-6816
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Country | US
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Telephone | 352-707-0707
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Fax | 269-753-1717
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Provider Business Mailing Address
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Address Line | 140 PINE TREE DR
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City | LEESBURG
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State | FL
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Zip | 34788-2806
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Country | US
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Telephone | 269-203-6516
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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 | 11020806
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License Number State | FL
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