Provider Demographics
NPI:1942818646
Name:CLARK, SHELLY A
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
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 1:1019 MILANO CIR APT 108
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7177
Mailing Address - Country:US
Mailing Address - Phone:813-390-4684
Mailing Address - Fax:
Practice Address - Street 1:744 W BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4902
Practice Address - Country:US
Practice Address - Phone:813-390-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-19
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management