MEDICARE: SUSAN MARIE CLARK PMHNP-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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11007813	FL

General Provider Information

NPI Number	:	1376161950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE CLARK PMHNP-BC

Provider Business Mailing Address
First Line	:	674 CORAL WAY
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-3127
Country	:	US
Telephone Number	:	334-220-2985
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 TREEMONTE DR
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-7977
Country	:	US
Telephone Number	:	800-614-4124
Fax Number	:	888-217-4124

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	02/27/2024

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