Provider Demographics
NPI:1023870896
Name:CLARK, BRAYLYNN DIANE (APRN)
Entity type:Individual
Prefix:
First Name:BRAYLYNN
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:FOLLANSBEE
Mailing Address - State:WV
Mailing Address - Zip Code:26037-1716
Mailing Address - Country:US
Mailing Address - Phone:740-424-1625
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1660
Practice Address - Country:US
Practice Address - Phone:304-845-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1113368207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine