Provider Demographics
NPI:1376161950
Name:CLARK, SUSAN MARIE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-3127
Mailing Address - Country:US
Mailing Address - Phone:334-220-2985
Mailing Address - Fax:
Practice Address - Street 1:300 TREEMONTE DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7977
Practice Address - Country:US
Practice Address - Phone:800-614-4124
Practice Address - Fax:888-217-4124
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007813363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health