Provider Demographics
NPI:1174521413
Name:CLARK, RHONDA D (CRNA)
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566
Mailing Address - Country:US
Mailing Address - Phone:850-939-6126
Mailing Address - Fax:850-939-3802
Practice Address - Street 1:928 MAR WALT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-862-4377
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2598982367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1789Medicare ID - Type Unspecified