Provider Demographics
NPI:1407528722
Name:CLARK, MIRANDA (FNP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-6103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4772 NAVY RD STE A
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-1927
Practice Address - Country:US
Practice Address - Phone:901-873-0930
Practice Address - Fax:901-873-0931
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95021208OtherCALIFORNIA BOARD OF REGISTERED NURSING