Provider Demographics
NPI:1750808093
Name:CLARK, CYNTHIA DAWN (NP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CYNDI
Other - Middle Name:DAWN
Other - Last Name:AINSWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1420 N GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-4111
Mailing Address - Country:US
Mailing Address - Phone:865-354-7799
Mailing Address - Fax:865-354-7797
Practice Address - Street 1:1420 N GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854
Practice Address - Country:US
Practice Address - Phone:865-354-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22984363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner