Provider Demographics
NPI:1568135945
Name:CLARK, BRITTANY ANN
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ANN
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 1:1775 FORRESTAL DR BLDG 33
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23551-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 FORRESTAL DR BLDG 33
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23551-0001
Practice Address - Country:US
Practice Address - Phone:910-449-9485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001011697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant