Provider Demographics
NPI:1871729889
Name:CLARK, MYRLITA SHAWN (NP,C)
Entity type:Individual
Prefix:MS
First Name:MYRLITA
Middle Name:SHAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:1999 W HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2828
Practice Address - Country:US
Practice Address - Phone:215-228-9300
Practice Address - Fax:215-228-9913
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASPO10333363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology