Healthcare Provider Details

I. General information

NPI: 1134044613
Provider Name (Legal Business Name): DIALISA CLARK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 OLEANDER RD
ALBANY GA
31705-4613
US

IV. Provider business mailing address

205 OLEANDER RD
ALBANY GA
31705-4613
US

V. Phone/Fax

Practice location:
  • Phone: 229-364-7396
  • Fax:
Mailing address:
  • Phone: 229-364-7396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2026041430
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: