Provider Demographics
NPI:1225666035
Name:CLARK, AMANDA LOUISE (RN, BSN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4321
Mailing Address - Country:US
Mailing Address - Phone:614-632-4049
Mailing Address - Fax:
Practice Address - Street 1:1871 SAVAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4726
Practice Address - Country:US
Practice Address - Phone:843-766-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC246707163WP0200X
SC26661363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Single Specialty