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General NPI Number Information
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NPI Number | 1801401112
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Entity Type | Individual
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Provider Name | COTENNA D. CLARK
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Gender | Female
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Dates
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Enumeration Date | 09/14/2020
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Last Update Date | 12/11/2025
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Provider Practice Location Address
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Address Line | 57 EXECUTIVE PARK SOUTH NE
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City | ATLANTA
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State | GA
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Zip | 30329-2288
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Country | US
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Telephone | 404-712-6929
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Fax | 404-712-0278
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Provider Business Mailing Address
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Address Line | 1857 CAMEO CT
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City | TUCKER
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State | GA
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Zip | 30084-7002
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Country | US
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Telephone | 678-485-1156
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | RN231376
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | RN231376
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License Number State | GA
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