Provider Demographics
NPI:1497708572
Name:CLARK, BENJAMIN S (FNP)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:ATTN WANDA BROWN
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-733-2131
Mailing Address - Fax:423-733-1055
Practice Address - Street 1:1861 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869
Practice Address - Country:US
Practice Address - Phone:423-733-2131
Practice Address - Fax:423-733-1055
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12038363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3643301Medicaid
TN4126469OtherBCBS
3703864Medicare PIN
3643301Medicare PIN
TN3643301Medicaid
3703865Medicare PIN