MEDICARE: SHANEEN CLARK APRN

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	11037260	FL

General Provider Information

NPI Number	:	1790216802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEEN CLARK APRN

Provider Business Mailing Address
First Line	:	7726 WINEGARD RD FL 21013
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7147
Country	:	US
Telephone Number	:	321-399-7353
Fax Number	:

Provider Business Practice Location Address
First Line	:	7726 WINEGARD RD FL 21013
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7147
Country	:	US
Telephone Number	:	321-399-7353
Fax Number	:

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

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	01/24/2025

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