MEDICARE: AMBER CLARK

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	RN240397	GA

General Provider Information

NPI Number	:	1992358485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER CLARK

Provider Business Mailing Address
First Line	:	1254 HOMER CITY WAY
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-3320
Country	:	US
Telephone Number	:	912-659-8923
Fax Number	:

Provider Business Practice Location Address
First Line	:	1254 HOMER CITY WAY
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-3320
Country	:	US
Telephone Number	:	912-659-8923
Fax Number	:

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

Provider Enumeration Date	:	07/23/2019
Last Update Date	:	07/23/2019

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Directions to “ AMBER CLARK ” Practice Location

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