Provider Demographics
NPI:1578368452
Name:CLARK, GRAYCEN (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:GRAYCEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 MICKELSON PL
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2004
Mailing Address - Country:US
Mailing Address - Phone:757-812-0539
Mailing Address - Fax:
Practice Address - Street 1:329 WESLEY ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1772
Practice Address - Country:US
Practice Address - Phone:423-631-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38211363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner