Provider Demographics
NPI:1235902545
Name:CLARK, MORANDA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MORANDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 BLACK ST
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-4122
Mailing Address - Country:US
Mailing Address - Phone:214-766-7083
Mailing Address - Fax:
Practice Address - Street 1:2021 N MACARTHUR BLVD STE 225
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2219
Practice Address - Country:US
Practice Address - Phone:972-253-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily