Provider Demographics
NPI:1609858364
Name:CLARK, LINDA LEE (NP)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 ALCOA HWY
Mailing Address - Street 2:SUITE 360
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1527
Mailing Address - Country:US
Mailing Address - Phone:865-546-2663
Mailing Address - Fax:865-546-9047
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:SUITE 360
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-546-2663
Practice Address - Fax:865-546-9047
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005696363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39098401Medicaid
2209545OtherCIGNA
TN1510218Medicaid
TN3909848Medicaid
2209545OtherCIGNA
TN1510218Medicaid
TN39098401Medicaid
TN103I502491Medicare PIN
TN3909848Medicare PIN
TN39098402Medicare PIN
TN3909848Medicaid