Provider Demographics
NPI:1922680321
Name:CLARK, BREANNA (CRNP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HOPE DR., P.O. BOX 855
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0855
Mailing Address - Country:US
Mailing Address - Phone:717-531-7180
Mailing Address - Fax:
Practice Address - Street 1:30 HOPE DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2036
Practice Address - Country:US
Practice Address - Phone:717-531-8887
Practice Address - Fax:717-531-4974
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023123363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily