Provider Demographics
NPI:1871884155
Name:CLARK, JUDITH YVETTE (APRN)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:YVETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7242 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-6749
Mailing Address - Country:US
Mailing Address - Phone:407-296-2273
Mailing Address - Fax:407-294-9740
Practice Address - Street 1:7242 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-6749
Practice Address - Country:US
Practice Address - Phone:407-296-2273
Practice Address - Fax:407-294-9740
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1442252363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY086KOtherBCBS
FL014122300Medicaid