Provider Demographics
NPI:1609145572
Name:CLARK, DEONNA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:DEONNA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
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 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:832-548-5076
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:6500 ROOKIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-5019
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:713-523-4897
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661103363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080462703Medicaid
661103OtherTX STATE BOARD OF NURSING APN LICENSURE
TX671835Medicare Oscar/Certification