Basic Information
| Provider Information | |||||||||
| NPI: | 1609858364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655462663 | ||||||||
| FaxNumber: | 8655469047 | ||||||||
| Practice Location | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655462663 | ||||||||
| FaxNumber: | 8655469047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000005696 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 39098401 | 05 | TN | MEDICAID | 2209545 | 01 | CIGNA | OTHER | 1510218 | 05 | TN | MEDICAID | 3909848 | 05 | TN | MEDICAID |