Provider Demographics
NPI:1053457135
Name:CLARK, CLAUDETTE VIVIENNE (MSN,RN,CPNP,IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:CLAUDETTE
Middle Name:VIVIENNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN,RN,CPNP,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 DICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2604
Mailing Address - Country:US
Mailing Address - Phone:210-595-3280
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DRIVE
Practice Address - Street 2:BROOKE ARMY MEDICAL CENTER
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-6200
Practice Address - Country:US
Practice Address - Phone:210-916-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-059903261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care