Provider Demographics
NPI:1174515795
Name:CLARK, BERNICE L (CRNP)
Entity type:Individual
Prefix:MS
First Name:BERNICE
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:132 GROVE ST
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1224
Practice Address - Country:US
Practice Address - Phone:856-354-2211
Practice Address - Fax:856-354-6181
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09214200363LF0000X
PASP007726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356Medicare Oscar/Certification
P36257Medicare UPIN