MEDICARE: MRS. ZANDRA N CLARK

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	253Z00000X	In Home Supportive Care Agency		FL

General Provider Information

NPI Number	:	1245926955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ZANDRA N CLARK

Provider Business Mailing Address
First Line	:	7350 BLANDING BLVD APT 118
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-4534
Country	:	US
Telephone Number	:	904-568-8258
Fax Number	:

Provider Business Practice Location Address
First Line	:	7350 BLANDING BLVD APT 118
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-4534
Country	:	US
Telephone Number	:	904-568-8258
Fax Number	:

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

Provider Enumeration Date	:	04/14/2023
Last Update Date	:	04/14/2023

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