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General NPI Number Information
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NPI Number | 1407369200
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Entity Type | Individual
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Provider Name | DOREN LOUISE CLARK NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 11/15/2017
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Last Update Date | 11/15/2017
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Provider Practice Location Address
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Address Line | 5505 PEACHTREE DUNWOODY RD
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City | ATLANTA
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State | GA
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Zip | 30342-1705
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Country | US
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Telephone | 678-705-2118
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Fax |
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Provider Business Mailing Address
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Address Line | 4009 ANDOVER CIR
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City | MCDONOUGH
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State | GA
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Zip | 30252-5502
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Country | US
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Telephone | 404-694-3236
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | F10170170
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License Number State | GA
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