Provider Demographics
NPI:1215306774
Name:CLARK, DEIRDRA (FNP (NP-C))
Entity type:Individual
Prefix:
First Name:DEIRDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP (NP-C)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 ELM HILL PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3108
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:
Practice Address - Street 1:5007 #2 VICTORY BLVD.
Practice Address - Street 2:
Practice Address - City:TABB
Practice Address - State:VA
Practice Address - Zip Code:23693-5606
Practice Address - Country:US
Practice Address - Phone:757-234-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily