Provider Demographics
NPI:1801401112
Name:CLARK, COTENNA D
Entity type:Individual
Prefix:
First Name:COTENNA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COTENNA
Other - Middle Name:D
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1857 CAMEO CT
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7002
Mailing Address - Country:US
Mailing Address - Phone:678-485-1156
Mailing Address - Fax:
Practice Address - Street 1:1857 CAMEO CT
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7002
Practice Address - Country:US
Practice Address - Phone:678-485-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN231376363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health