Provider Demographics
NPI:1598082059
Name:CLARK, JANELL LANICE (CRNP)
Entity type:Individual
Prefix:
First Name:JANELL
Middle Name:LANICE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JANELL
Other - Middle Name:LANICE
Other - Last Name:BUTTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1738 W CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-1546
Mailing Address - Country:US
Mailing Address - Phone:215-548-3390
Mailing Address - Fax:215-549-8998
Practice Address - Street 1:1738 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126-1546
Practice Address - Country:US
Practice Address - Phone:215-548-3390
Practice Address - Fax:215-549-8998
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010694363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner