Provider Demographics
NPI:1619777935
Name:CLARK, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97268 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-7362
Mailing Address - Country:US
Mailing Address - Phone:734-678-6117
Mailing Address - Fax:
Practice Address - Street 1:1501 MILLPOND RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-7636
Practice Address - Country:US
Practice Address - Phone:229-226-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program