Provider Demographics
NPI:1376985036
Name:CLARK, COURTNEY B (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:B
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2131 N LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-4455
Mailing Address - Country:US
Mailing Address - Phone:931-762-6545
Mailing Address - Fax:
Practice Address - Street 1:2131 N LOCUST AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-4455
Practice Address - Country:US
Practice Address - Phone:931-762-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710089Medicaid
TN3710089Medicare PIN