Provider Demographics
NPI:1609120567
Name:CLARK, KATHY (CAT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 STEEPLE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5479
Mailing Address - Country:US
Mailing Address - Phone:678-592-0935
Mailing Address - Fax:770-235-5103
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:678-592-0935
Practice Address - Fax:770-234-5103
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QH0000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHematology
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other