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 1:853 N CHURCH ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3077
Mailing Address - Country:US
Mailing Address - Phone:864-560-1558
Mailing Address - Fax:864-560-1565
Practice Address - Street 1:853 N CHURCH ST STE 510
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3077
Practice Address - Country:US
Practice Address - Phone:864-560-1558
Practice Address - Fax:864-560-1565
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCLL86080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program