Provider Demographics
NPI:1912236209
Name:CLARK, KATHLEEN LINTON (APRN-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LINTON
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 DOWNWOOD CIR NW
Mailing Address - Street 2:STE 550
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1624
Mailing Address - Country:US
Mailing Address - Phone:404-351-0205
Mailing Address - Fax:404-351-4187
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:STE 550
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1624
Practice Address - Country:US
Practice Address - Phone:404-351-0205
Practice Address - Fax:404-351-4187
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN241302363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003188941AMedicaid
GA20250I2945Medicare PIN