Healthcare Provider Details

I. General information

NPI: 1801401112
Provider Name (Legal Business Name): COTENNA D. CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COTENNA D GARDNER NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 EXECUTIVE PARK SOUTH NE
ATLANTA GA
30329-2288
US

IV. Provider business mailing address

1857 CAMEO CT
TUCKER GA
30084-7002
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-6929
  • Fax: 404-712-0278
Mailing address:
  • Phone: 678-485-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN231376
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN231376
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: