Provider Demographics
NPI:1194498634
Name:CLARK, CALLIE BIBB (DNP, FNP-C)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:BIBB
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-0925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2258 WRIGHTSBORO RD STE 400
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4788
Practice Address - Country:US
Practice Address - Phone:706-724-4400
Practice Address - Fax:706-724-6003
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA254429363L00000X
GANP000357363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty