Basic Information
| Provider Information | |||||||||
| NPI: | 1770218356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK-JOHNSON | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125271000 | ||||||||
| FaxNumber: | 9125271155 | ||||||||
| Practice Location | |||||||||
| Address1: | 5354 REYNOLDS ST STE 411 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123552800 | ||||||||
| FaxNumber: | 9123559444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2022 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN171140 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.