Provider Demographics
NPI:1215064852
Name:NULL, ELIZABETH ANN (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:NULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:NULL CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-490-7348
Mailing Address - Fax:931-490-7349
Practice Address - Street 1:1222 TROTWOOD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6436
Practice Address - Country:US
Practice Address - Phone:931-490-7348
Practice Address - Fax:931-490-7349
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN456712084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710089Medicaid
3710089Medicare PIN