Provider Demographics
NPI:1770583924
Name:CLARK, BEVERLY ANNE-MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANNE-MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:13808 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:13808 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7948
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5313367500000X
NY3527951174400000X
NY352795367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR0A641Medicare ID - Type Unspecified