Provider Demographics
NPI:1043213457
Name:CLARK, WANDA KAYE (FNP)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:KAYE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1151 CAMDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3014
Mailing Address - Country:US
Mailing Address - Phone:803-909-6363
Mailing Address - Fax:803-909-6364
Practice Address - Street 1:1151 CAMDEN AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3014
Practice Address - Country:US
Practice Address - Phone:803-909-6363
Practice Address - Fax:803-909-6364
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1484363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3059Medicaid
SCP66128Medicare UPIN