Provider Demographics
NPI:1366004889
Name:SCOTT, CLEMENTINA ROSE
Entity Type:Individual
Prefix:
First Name:CLEMENTINA
Middle Name:ROSE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 BUSINESS CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-2744
Mailing Address - Country:US
Mailing Address - Phone:713-842-7833
Mailing Address - Fax:
Practice Address - Street 1:23900 KATY FWY
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1323
Practice Address - Country:US
Practice Address - Phone:713-500-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-04
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141984207P00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty