Healthcare Provider Details

I. General information

NPI: 1053592709
Provider Name (Legal Business Name): TRUDY BOVIE CLARK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 LANEY WALKER BLVD
AUGUSTA GA
30901-2960
US

IV. Provider business mailing address

950 LANEY WALKER BLVD
AUGUSTA GA
30901-2960
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-5800
  • Fax: 706-721-5903
Mailing address:
  • Phone: 706-721-5800
  • Fax: 706-721-5903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN182103
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: