Provider Demographics
NPI:1962954305
Name:CLARK, TERRI JO (FNP-BC, MSN)
Entity type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:JO
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-BC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-2806
Mailing Address - Country:US
Mailing Address - Phone:269-203-6516
Mailing Address - Fax:
Practice Address - Street 1:8550 NE 138TH LN BLDG 600
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6816
Practice Address - Country:US
Practice Address - Phone:352-707-0707
Practice Address - Fax:269-753-1717
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020806363LF0000X
MI4704279158363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty