Provider Demographics
NPI:1134849672
Name:CLARK, CLAIRE BRICELY (AGNP-C)
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:BRICELY
Last Name:CLARK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 KENAN ST NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893
Mailing Address - Country:US
Mailing Address - Phone:252-315-9546
Mailing Address - Fax:
Practice Address - Street 1:2460 CURTIS ELLIS DR BLDG 100
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2237
Practice Address - Country:US
Practice Address - Phone:252-962-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016831363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care