MEDICARE: MRS. DAWN M. CLARK CRNA

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	367500000X	Certified Registered Nurse Anesthetist	750	SC

General Provider Information

NPI Number	:	1497703938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DAWN M. CLARK CRNA

Provider Business Mailing Address
First Line	:	209 SILVERCREEK DR
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-8089
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1735 TAYLOR ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3452
Country	:	US
Telephone Number	:	803-254-8449
Fax Number	:

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	10/02/2007

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