Provider Demographics
NPI:1477107704
Name:CLARK, SABRINA WILLIS (NP)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:WILLIS
Last Name:CLARK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 BROAD AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2460
Mailing Address - Country:US
Mailing Address - Phone:228-867-4855
Mailing Address - Fax:
Practice Address - Street 1:1340 BROAD AVE STE 440
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2460
Practice Address - Country:US
Practice Address - Phone:228-867-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA207344OtherSTATE LICENSE