Provider Demographics
NPI:1033795232
Name:CLARK BERGERON CARTER, STACY LEA (APRN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEA
Last Name:CLARK BERGERON CARTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-265-7750
Practice Address - Fax:954-276-0280
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011922363LA2100X
FLAPRN11011922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113475400Medicaid