Provider Demographics
NPI:1740728690
Name:CLARK, LEILA (NP)
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:106 PEARL DR STE 106
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7510
Practice Address - Country:US
Practice Address - Phone:706-670-1001
Practice Address - Fax:706-935-3900
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA60018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily