Provider Demographics
NPI:1457423055
Name:CLARK, CAROL D (ARNP, BC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13880 SHELL POINT PLAZA
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3504
Mailing Address - Country:US
Mailing Address - Phone:239-454-2146
Mailing Address - Fax:239-454-2111
Practice Address - Street 1:13880 SHELL POINT PLAZA
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3504
Practice Address - Country:US
Practice Address - Phone:239-466-1111
Practice Address - Fax:239-454-2111
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9191162363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54479Medicare UPIN