Provider Demographics
NPI:1508379504
Name:CLARK, BRENDA M (FNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26321 N BABBLING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-6327
Mailing Address - Country:US
Mailing Address - Phone:623-210-9852
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN166497163W00000X
AZAP10601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse