Provider Demographics
NPI:1730073404
Name:CLARK, AMANDA LEIGH (CSFA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:CLARK
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 OAK COVE DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-5054
Mailing Address - Country:US
Mailing Address - Phone:228-324-8126
Mailing Address - Fax:
Practice Address - Street 1:5655 FRIST BLVD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2053
Practice Address - Country:US
Practice Address - Phone:615-316-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS214724246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant