Provider Demographics
NPI:1083675672
Name:CLARK, TAMMY V (ATC)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:V
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:11150 SUNBURST LN
Mailing Address - Street 2:APT. A
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7654
Mailing Address - Country:US
Mailing Address - Phone:540-898-4655
Mailing Address - Fax:540-373-8643
Practice Address - Street 1:2300 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3340
Practice Address - Country:US
Practice Address - Phone:540-372-1100
Practice Address - Fax:540-373-8643
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260008202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer