MEDICARE: WENDY S CLARK 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	363L00000X	Nurse Practitioner	71001332A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	500024448	OTHER	IN	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366433526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY S CLARK FNP-BC

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 E. DUPONT RD.
Second Line	:	SUITE 6
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-480-2600
Fax Number	:	260-496-8077

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	10/15/2022

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Directions to “ WENDY S CLARK FNP-BC” Practice Location

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