Provider Demographics
NPI:1003833559
Name:CLARK, TONI (RN, MS, CFNP)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, MS, CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849881
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0001
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:2500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4169
Practice Address - Country:US
Practice Address - Phone:713-456-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX576086363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP083N0230Medicaid
TX8B1684Medicare PIN
TX1003833559Medicare PIN
TX83N023Medicare PIN
TX82N873Medicare PIN
TX8B1683Medicare PIN
S75616Medicare UPIN
TX8C8566Medicare PIN