MEDICARE: ALYSSA CLARK DNP, FNP-BC

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	4704334727NSA2109N	MI
2	363LF0000X	Family Nurse Practitioner	4704334727	MI

General Provider Information

NPI Number	:	1184293805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA CLARK DNP, FNP-BC

Provider Business Mailing Address
First Line	:	53075 PIMPERNIL LN
Second Line	:
City	:	CHESTERFIELD
State	:	MI
Zip	:	48051-1779
Country	:	US
Telephone Number	:	586-453-8682
Fax Number	:

Provider Business Practice Location Address
First Line	:	24675 LAHSER RD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3238
Country	:	US
Telephone Number	:	586-453-8682
Fax Number	:

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

Provider Enumeration Date	:	06/18/2021
Last Update Date	:	11/10/2025

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