Provider Demographics
NPI:1295080141
Name:CLARK, MICHELLE E (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:E
Other - Last Name:BRINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-3660
Mailing Address - Fax:239-343-4133
Practice Address - Street 1:708 DEL PRADO BLVD S STE 7
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2676
Practice Address - Country:US
Practice Address - Phone:239-424-3660
Practice Address - Fax:239-343-4133
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9291822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006113900Medicaid
FLGI608ZOtherMEDICARE
FL02456100Medicaid
FLY0C94OtherBCBS