Provider Demographics
NPI:1215353743
Name:CLARK, DONNA PATRICIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:PATRICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:DR
Other - First Name:DONNA
Other - Middle Name:PATRICIA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP, FNP-BC
Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:757-728-7133
Practice Address - Street 1:12388 WARWICK BLVD STE 302
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3858
Practice Address - Country:US
Practice Address - Phone:757-679-6058
Practice Address - Fax:757-926-5465
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017141207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily