Provider Demographics
NPI:1548086838
Name:CLARK, TAMMY LYNN (PTA)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 GREENE 561 RD
Mailing Address - Street 2:
Mailing Address - City:MARMADUKE
Mailing Address - State:AR
Mailing Address - Zip Code:72443
Mailing Address - Country:US
Mailing Address - Phone:870-573-0484
Mailing Address - Fax:
Practice Address - Street 1:1707 LINWOOD DR STE E
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5365
Practice Address - Country:US
Practice Address - Phone:870-586-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA3991225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant