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NPI Code Detail

MEDICARE: AMY K CLARK CRNA

MEDICARE: AMY K CLARK CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse AnesthetistRN063977LA

General Provider Information

NPI Number : 1790057222
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY K CLARK CRNA
Provider Business Mailing Address
First Line : 6580 JUDSON RD
Second Line :
City : LONGVIEW
State : TX
Zip : 75605-7076
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6580 JUDSON RD
Second Line :
City : LONGVIEW
State : TX
Zip : 75605-7076
Country : US
Telephone Number : 800-939-7440
Fax Number : 903-663-3629
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/30/2012
Last Update Date : 01/30/2012

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Directions to “ AMY K CLARK CRNA” Practice Location

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