Provider Demographics
NPI:1033894043
Name:CLARK, DAKOTA ELLIS (FNP)
Entity type:Individual
Prefix:MRS
First Name:DAKOTA
Middle Name:ELLIS
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 WOODS COVE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2428
Mailing Address - Country:US
Mailing Address - Phone:256-218-3340
Mailing Address - Fax:256-218-3655
Practice Address - Street 1:380 WOODS COVE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2428
Practice Address - Country:US
Practice Address - Phone:256-218-3340
Practice Address - Fax:256-218-3655
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-156690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily