| Doctor Name: | CHARLENE CLARK |
| NPI Number: | 1144621756 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | FNP |
| License Number: | 19070 |
| Business Practice Address: | 629 Nuckolls Rd Bolivar, TN - 380081599 |
| Business Phone Number: | 7316583388 |
| Business Fax Number: | 7316584079 |
| Mailing Address: | Po Box 720, BOLIVAR |
| State: | TN |
| Postal Code: | 380080720 |
| Phone Number: | 7316583388 |
| Fax Number: | 7316584079 |
| NPI Enumeration Date: | 09/15/2014 |
| NPI Last Update Date: | 09/15/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 19070 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |