Provider Demographics
NPI:1750169504
Name:CLARK, GABRIELA (FNP-C)
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 CRABAPPLE ROAD
Mailing Address - Street 2:BLDG. A, SUITE 104-B
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:770-645-0017
Mailing Address - Fax:770-645-0224
Practice Address - Street 1:11050 CRABAPPLE ROAD
Practice Address - Street 2:BLDG. A, SUITE 104-B
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075
Practice Address - Country:US
Practice Address - Phone:770-645-0017
Practice Address - Fax:770-645-0224
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN294112363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN294112OtherGEORGIA BOARD OF NURSING