Provider Demographics
NPI:1922680321
Name:CLARK, BREANNA (CRNP)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HOPE DR., P.O. BOX 855
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0855
Mailing Address - Country:US
Mailing Address - Phone:717-531-7180
Mailing Address - Fax:
Practice Address - Street 1:3100 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-3548
Practice Address - Country:US
Practice Address - Phone:717-948-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023123363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily