Provider Demographics
NPI:1497316541
Name:CLARK, EDWENA CHENELLE (PTA)
Entity Type:Individual
Prefix:
First Name:EDWENA
Middle Name:CHENELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-3019
Mailing Address - Country:US
Mailing Address - Phone:615-355-0350
Mailing Address - Fax:615-355-5549
Practice Address - Street 1:200 MAYFIELD DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3019
Practice Address - Country:US
Practice Address - Phone:615-355-0350
Practice Address - Fax:615-355-5549
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3098225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant