Provider Demographics
NPI:1699867127
Name:CLARK, TAMMY ANNA (CRNA)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ANNA
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:ANNA
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:763 GATEWOOD RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4203
Mailing Address - Country:US
Mailing Address - Phone:404-908-0668
Mailing Address - Fax:
Practice Address - Street 1:763 GATEWOOD RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4203
Practice Address - Country:US
Practice Address - Phone:404-908-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699867127Medicaid
VA1699867127Medicaid