Provider Demographics
NPI:1821696089
Name:CLARK, AUDRIANA
Entity Type:Individual
Prefix:MRS
First Name:AUDRIANA
Middle Name:
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 1:7333 PINE FOREST RD LOT 70
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-3910
Mailing Address - Country:US
Mailing Address - Phone:850-356-0364
Mailing Address - Fax:
Practice Address - Street 1:7333 PINE FOREST RD LOT 70
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-3910
Practice Address - Country:US
Practice Address - Phone:850-356-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion