Basic Information
| Provider Information | |||||||||
| NPI: | 1518277961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SUMMER | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857345 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854405 | ||||||||
| FaxNumber: | 6828854407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 724311 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0222X | 724311 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care | 363LP0200X | AP118982 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.