Provider Demographics
NPI:1629373881
Name:CLARK, BRENDA JILL (ARNP FAMILY NURSE PR)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JILL
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP FAMILY NURSE PR
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JILL
Other - Last Name:WOONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2312 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-9109
Mailing Address - Country:US
Mailing Address - Phone:515-720-9903
Mailing Address - Fax:
Practice Address - Street 1:2312 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-9109
Practice Address - Country:US
Practice Address - Phone:515-720-9903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-106433363LF0000X
IAA106433363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA161583Medicare PIN