Provider Demographics
NPI:1063871341
Name:CLARK, KRISTINA (APRN)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9886 E. VERONA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-6670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 SW SAINT LUCIE WEST BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1709
Practice Address - Country:US
Practice Address - Phone:772-879-1112
Practice Address - Fax:772-879-1167
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9324590163W00000X
FLARNP9324590363LF0000X
FLAPRN9324590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse