MEDICARE: DEIRDRA CLARK FNP (NP-C)

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	0024172570	VA

General Provider Information

NPI Number	:	1215306774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRA CLARK FNP (NP-C)

Provider Business Mailing Address
First Line	:	2620 ELM HILL PIKE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-3108
Country	:	US
Telephone Number	:	615-425-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5007 #2 VICTORY BLVD.
Second Line	:
City	:	TABB
State	:	VA
Zip	:	23693-5606
Country	:	US
Telephone Number	:	757-234-7987
Fax Number	:

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

Provider Enumeration Date	:	09/15/2015
Last Update Date	:	09/15/2015

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