Provider Demographics
NPI:1598338113
Name:CLARK, SAVANNAH EMILY
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:EMILY
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6450
Mailing Address - Country:US
Mailing Address - Phone:866-401-3057
Mailing Address - Fax:318-868-6430
Practice Address - Street 1:575 STANTON RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2344
Practice Address - Country:US
Practice Address - Phone:251-471-7207
Practice Address - Fax:251-471-7468
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2053363A00000X
ALPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant