Provider Demographics
NPI:1356340681
Name:CLARK, WANDA LU (FNP)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:LU
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79072-6737
Mailing Address - Country:US
Mailing Address - Phone:806-293-8561
Mailing Address - Fax:806-293-8413
Practice Address - Street 1:3113 ROSS ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79103-2700
Practice Address - Country:US
Practice Address - Phone:806-374-7341
Practice Address - Fax:806-322-0533
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509539363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142123201Medicaid
TX85N188OtherBCBS TX
TX85N188Medicare PIN
P12998Medicare UPIN