Provider Demographics
NPI:1083250252
Name:CLARK, BRITANY
Entity Type:Individual
Prefix:
First Name:BRITANY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6338 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-1616
Mailing Address - Country:US
Mailing Address - Phone:954-914-3191
Mailing Address - Fax:954-960-2126
Practice Address - Street 1:6338 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33068-1616
Practice Address - Country:US
Practice Address - Phone:954-960-2126
Practice Address - Fax:954-960-2126
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5228154164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1083250252Medicaid