Basic Information
| Provider Information | |||||||||
| NPI: | 1750346847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RNC MSN NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 PENNSYLVANIA AVE | ||||||||
| Address2: | # 740 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172502892 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1325 PENNSYLVANIA AVE | ||||||||
| Address2: | #740 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172502892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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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 | 363LN0005X | 505735 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0000X | CNP-02165 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
No ID Information.