Provider Demographics
NPI:1922061886
Name:CLARKE, MARY CHRISTINE (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CHRISTINE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25518 WOUNDED KNEE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261
Mailing Address - Country:US
Mailing Address - Phone:210-319-8333
Mailing Address - Fax:830-714-4621
Practice Address - Street 1:25518 WOUNDED KNEE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261
Practice Address - Country:US
Practice Address - Phone:210-319-8333
Practice Address - Fax:830-714-4621
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX748916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD00Medicare UPIN