Provider Demographics
NPI:1760002893
Name:CLARK, STEPHANIE NICOLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1050 EAGLES LANDING PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9200
Mailing Address - Country:US
Mailing Address - Phone:678-289-1988
Mailing Address - Fax:
Practice Address - Street 1:1050 EAGLES LANDING PKWY STE 202
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9200
Practice Address - Country:US
Practice Address - Phone:678-289-1988
Practice Address - Fax:678-289-1512
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN225891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily