Provider Demographics
NPI:1114760204
Name:CLARK, ANNIE ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:6602 HAMPTON BEND CIR SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-8200
Mailing Address - Country:US
Mailing Address - Phone:256-603-9685
Mailing Address - Fax:
Practice Address - Street 1:6602 HAMPTON BEND CIR SE
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-8200
Practice Address - Country:US
Practice Address - Phone:256-603-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant