Provider Demographics
NPI:1194402172
Name:CLARK, BRANDI (CRNP)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6247
Mailing Address - Country:US
Mailing Address - Phone:814-201-2309
Mailing Address - Fax:814-201-2389
Practice Address - Street 1:914 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6247
Practice Address - Country:US
Practice Address - Phone:814-201-2309
Practice Address - Fax:814-201-2389
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027557363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner