Provider Demographics
NPI:1487854162
Name:CLARK, JOHANNA J (CSA)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:MS
Other - First Name:JOHANNA
Other - Middle Name:JOY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8409 DUNWOODY PL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-3367
Mailing Address - Country:US
Mailing Address - Phone:770-594-1351
Mailing Address - Fax:
Practice Address - Street 1:8409 DUNWOODY PL
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-3367
Practice Address - Country:US
Practice Address - Phone:770-594-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist