Provider Demographics
NPI:1477916906
Name:CLARK, TENICIA (APN, FNP-C)
Entity Type:Individual
Prefix:
First Name:TENICIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-3285
Mailing Address - Country:US
Mailing Address - Phone:423-798-1749
Mailing Address - Fax:423-798-1755
Practice Address - Street 1:810 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3285
Practice Address - Country:US
Practice Address - Phone:423-798-1749
Practice Address - Fax:423-798-1755
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020533Medicaid
TNP01672905OtherRR MEDICARE
TN103I503478Medicare PIN