Provider Demographics
NPI:1578323820
Name:CLARK, ESCOLASTICA (RN)
Entity Type:Individual
Prefix:
First Name:ESCOLASTICA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:16 RAINTREE CIR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 KENNEDY ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4150
Practice Address - Country:US
Practice Address - Phone:386-326-3207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9624319163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse