Provider Demographics
NPI:1215486444
Name:CLARK, STEPHANIE NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:105 KATHERINE DR
Mailing Address - Street 2:STE G
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8857
Mailing Address - Country:US
Mailing Address - Phone:919-731-6068
Mailing Address - Fax:919-731-6025
Practice Address - Street 1:2700 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9494
Practice Address - Country:US
Practice Address - Phone:919-731-6068
Practice Address - Fax:919-731-6025
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901448367500000X
AL111055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty