Provider Demographics
NPI:1992428361
Name:CLARK, RENNA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:RENNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 FETTLER PARK DR UNIT A5
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1946
Mailing Address - Country:US
Mailing Address - Phone:703-441-3555
Mailing Address - Fax:
Practice Address - Street 1:955 E WONDER RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554
Practice Address - Country:US
Practice Address - Phone:540-741-7893
Practice Address - Fax:540-741-9778
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024184881363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health