Provider Demographics
NPI:1528094604
Name:CLARK, JOANNA HOPKINS (CPNP)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:HOPKINS
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 FRANKLIN RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7803
Mailing Address - Country:US
Mailing Address - Phone:770-732-6007
Mailing Address - Fax:770-732-8242
Practice Address - Street 1:777 FRANKLIN RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7803
Practice Address - Country:US
Practice Address - Phone:770-732-6007
Practice Address - Fax:770-732-8242
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60471208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA818552480AMedicaid
GA003104606BMedicaid
GA270040208OtherTIN