Provider Demographics
NPI:1770218356
Name:CLARK-JOHNSON, TRACEY AMANDA
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:AMANDA
Last Name:CLARK-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-2917
Mailing Address - Country:US
Mailing Address - Phone:912-527-1000
Mailing Address - Fax:912-527-1155
Practice Address - Street 1:5354 REYNOLDS ST STE 411
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6011
Practice Address - Country:US
Practice Address - Phone:912-355-2800
Practice Address - Fax:912-355-9444
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily