Provider Demographics
NPI:1598152233
Name:CLARK, AUBREY (ARNP FNP-BC)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2171
Mailing Address - Country:US
Mailing Address - Phone:937-382-5553
Mailing Address - Fax:937-382-4654
Practice Address - Street 1:630 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2171
Practice Address - Country:US
Practice Address - Phone:937-382-5553
Practice Address - Fax:937-382-4654
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028469363LF0000X
FL9346495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014796400Medicaid
FLID780ZMedicare PIN