Provider Demographics
NPI:1316933567
Name:CLARK, CAROLYN B (ARNP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 5699
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-5699
Mailing Address - Country:US
Mailing Address - Phone:941-365-0433
Mailing Address - Fax:941-954-2064
Practice Address - Street 1:1217 S EAST AVE STE 104
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2350
Practice Address - Country:US
Practice Address - Phone:941-365-0433
Practice Address - Fax:941-954-2064
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1360702363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL753072541OtherTAX ID
FLE6869YMedicare PIN
FL753072541OtherTAX ID