Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | AP143273 | TX |
NPI | 1043851645 |
---|---|
Provider Name | Whitney Clark |
First Address | Lufkin, TX 75901-1777 |
Second Address | Lufkin, TX 75904-3124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2019 |
Last Update Date | 04/10/2019 |