Healthcare Provider Details

I. General information

NPI: 1922771195
Provider Name (Legal Business Name): CLARK R. GWALTNEY DNP-PACNP, RNFA, CPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

IV. Provider business mailing address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

V. Phone/Fax

Practice location:
  • Phone: 901-595-3300
  • Fax:
Mailing address:
  • Phone: 901-595-6339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number29917
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: