Healthcare Provider Details

I. General information

NPI: 1760076053
Provider Name (Legal Business Name): JANAE ALISE CLARK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANAE ALISE HERZOG

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 MEMORIAL DR STE 100
DALTON GA
30720-8662
US

IV. Provider business mailing address

1107 MEMORIAL DR STE 100
DALTON GA
30720-8662
US

V. Phone/Fax

Practice location:
  • Phone: 706-529-3072
  • Fax: 706-529-3077
Mailing address:
  • Phone: 706-529-3072
  • Fax: 706-529-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11011659
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN-NP719288
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberGAA-NP004633
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: