Provider Demographics
NPI:1740986629
Name:CLARK, MARGUERITE LILLIE (NP)
Entity type:Individual
Prefix:MRS
First Name:MARGUERITE
Middle Name:LILLIE
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 1:12200 RENFERT WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5654
Mailing Address - Country:US
Mailing Address - Phone:214-784-3185
Mailing Address - Fax:
Practice Address - Street 1:12200 RENFERT WAY STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5654
Practice Address - Country:US
Practice Address - Phone:512-451-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178492363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology