Provider Demographics
NPI:1184387672
Name:CLARK, BEVERLY W (FNP-C)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:DARLENE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4735 HIGHWAY 490 RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-9366
Mailing Address - Country:US
Mailing Address - Phone:662-361-8338
Mailing Address - Fax:
Practice Address - Street 1:78 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2490
Practice Address - Country:US
Practice Address - Phone:662-361-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904987363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily