Provider Demographics
NPI:1891263299
Name:FARMER CLARK, MATTIE MAE (CST/CSFA)
Entity Type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:MAE
Last Name:FARMER CLARK
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 COVINGTON TER
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5771
Mailing Address - Country:US
Mailing Address - Phone:386-295-3122
Mailing Address - Fax:
Practice Address - Street 1:PIEDMONT FAYETTE HOSPITAL
Practice Address - Street 2:1255 HIGHWAY 54 WEST
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-719-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant