Provider Demographics
NPI:1134841943
Name:CLARK, CODY ALEXANDER (FNP-BC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12155 HIDDEN TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4577
Mailing Address - Country:US
Mailing Address - Phone:702-524-8579
Mailing Address - Fax:
Practice Address - Street 1:1400 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2205
Practice Address - Country:US
Practice Address - Phone:901-759-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily