Provider Demographics
NPI:1588213128
Name:CLARK, DONELLE LAMONT (DNP)
Entity Type:Individual
Prefix:DR
First Name:DONELLE
Middle Name:LAMONT
Last Name:CLARK
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FARROW CT
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2768
Mailing Address - Country:US
Mailing Address - Phone:228-365-1241
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700A7878
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-327-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61073178363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty