MEDICARE: MS. BERNICE L CLARK C.R.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	26NN09214200	NJ
2	363LF0000X	Family Nurse Practitioner	SP007726	PA

General Provider Information

NPI Number	:	1174515795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BERNICE L CLARK C.R.N.P.

Provider Business Mailing Address
First Line	:	402 LIPPINCOTT DR
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4112
Country	:	US
Telephone Number	:	856-782-3300
Fax Number	:	856-504-8029

Provider Business Practice Location Address
First Line	:	132 GROVE ST
Second Line	:
City	:	HADDONFIELD
State	:	NJ
Zip	:	08033-1224
Country	:	US
Telephone Number	:	856-354-2211
Fax Number	:	856-354-6181

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	04/08/2016

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