Provider Demographics
NPI:1376985036
Name:CLARK, COURTNEY B (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:B
Other - Last Name:CARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-380-4072
Mailing Address - Fax:931-490-7043
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-380-4072
Practice Address - Fax:931-490-7043
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710089Medicaid
TN3710089Medicare PIN