Provider Demographics
NPI:1740466622
Name:WASMUTH, CLARICE WHITLOCK (RN-CS, ANP)
Entity type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:WHITLOCK
Last Name:WASMUTH
Suffix:
Gender:F
Credentials:RN-CS, ANP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3720 DAVINCI CT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-7627
Mailing Address - Country:US
Mailing Address - Phone:770-582-4186
Mailing Address - Fax:
Practice Address - Street 1:3720 DAVINCI CT
Practice Address - Street 2:SUITE 400
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7627
Practice Address - Country:US
Practice Address - Phone:770-582-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113689163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146803AMedicaid