Provider Demographics
NPI:1396226114
Name:CLARK, CATHERINE LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:FLEISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 143754
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6537
Mailing Address - Country:US
Mailing Address - Phone:770-364-3626
Mailing Address - Fax:
Practice Address - Street 1:11866 HASTINGS BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LOVEJOY
Practice Address - State:GA
Practice Address - Zip Code:30250
Practice Address - Country:US
Practice Address - Phone:770-305-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07182091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily