Provider Demographics
NPI:1780030734
Name:CLARK, GRACE (AGPCNP-B)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:AGPCNP-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6831
Mailing Address - Country:US
Mailing Address - Phone:770-948-5578
Mailing Address - Fax:
Practice Address - Street 1:3825 MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6831
Practice Address - Country:US
Practice Address - Phone:770-948-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN243044363LP2300X
GARN 243044363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care