Provider Demographics
NPI:1952966467
Name:CLARK-FUQUA, KATLYN BAILEY (MD)
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:BAILEY
Last Name:CLARK-FUQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATLYN
Other - Middle Name:BAILEY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1855 TANNER WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-8332
Mailing Address - Country:US
Mailing Address - Phone:865-374-6272
Mailing Address - Fax:865-374-2100
Practice Address - Street 1:1855 TANNER WAY STE 200
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8332
Practice Address - Country:US
Practice Address - Phone:865-374-6272
Practice Address - Fax:865-374-2100
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71338207Q00000X
SCLL86080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ095495Medicaid