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General NPI Number Information
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NPI Number | 1588213128
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Entity Type | Individual
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Provider Name | DONELLE LAMONT CLARK DNP
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Gender | Male
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Dates
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Enumeration Date | 09/06/2019
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 655 7TH ST BLDG 700A7878
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City | ROBINS AFB
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State | GA
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Zip | 31098-2227
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Country | US
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Telephone | 478-327-8398
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Fax |
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Provider Business Mailing Address
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Address Line | 655 7TH ST BLDG 700
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City | ROBINS AFB
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State | GA
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Zip | 31098-2227
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Country | US
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Telephone | 478-327-8398
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP61073178
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License Number State | WA
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