Provider Demographics
NPI:1922771195
Name:GWALTNEY, CLARK R (DNP-PACNP, RNFA, CPN)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:R
Last Name:GWALTNEY
Suffix:
Gender:M
Credentials:DNP-PACNP, RNFA, CPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 N DUNLAP ST FL 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2802
Mailing Address - Country:US
Mailing Address - Phone:901-287-7337
Mailing Address - Fax:
Practice Address - Street 1:848 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29917363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN29917OtherTENNESSEE LICENSE