Basic Information
| Provider Information | |||||||||
| NPI: | 1649258633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORRESTER | ||||||||
| FirstName: | CLARA | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 4405 RIVER OAKS BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761142326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176241770 | ||||||||
| FaxNumber: | 8176251287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 531980 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 137345810 | 01 | TX | CSHCN GROUP | OTHER | 062616004 | 05 | TX | MEDICAID | 062616005 | 01 | TX | CSHCN | OTHER | 00U87Z | 01 | TX | MEDICARE PIN GROUP | OTHER | 140442852 | 01 | TX | MEDICAID GROUP | OTHER |