MEDICARE: ASHLEY T. CLARK FNP-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	23387	SC

General Provider Information

NPI Number	:	1457993677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY T. CLARK FNP-C

Provider Business Mailing Address
First Line	:	2050 CORPORATE CENTRE DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-7428
Country	:	US
Telephone Number	:	843-698-3120
Fax Number	:	888-900-2640

Provider Business Practice Location Address
First Line	:	2050 CORPORATE CENTRE DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-7428
Country	:	US
Telephone Number	:	843-698-3120
Fax Number	:	888-900-2640

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

Provider Enumeration Date	:	10/09/2019
Last Update Date	:	02/01/2023

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