MEDICARE: COTENNA D. CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	RN231376	GA
2	363LA2200X	Adult Health Nurse Practitioner	RN231376	GA

General Provider Information

NPI Number	:	1801401112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COTENNA D. CLARK

Provider Business Mailing Address
First Line	:	1857 CAMEO CT
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-7002
Country	:	US
Telephone Number	:	678-485-1156
Fax Number	:

Provider Business Practice Location Address
First Line	:	57 EXECUTIVE PARK SOUTH NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2288
Country	:	US
Telephone Number	:	404-712-6929
Fax Number	:	404-712-0278

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	12/11/2025

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