MEDICARE: MRS. LISA L. CLARK FNP

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	RN089162	GA

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	:	1801160353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA L. CLARK FNP

Provider Business Mailing Address
First Line	:	704 BREEDLOVE DR STE A
Second Line	:
City	:	MONROE
State	:	GA
Zip	:	30655-2054
Country	:	US
Telephone Number	:	803-818-6900
Fax Number	:

Provider Business Practice Location Address
First Line	:	704 BREEDLOVE DR STE A
Second Line	:
City	:	MONROE
State	:	GA
Zip	:	30655-2054
Country	:	US
Telephone Number	:	803-818-6900
Fax Number	:

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	08/14/2025

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