Healthcare Provider Details

I. General information

NPI: 1568962512
Provider Name (Legal Business Name): GERRI BOB CLAWSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 BEDIVERE ST
BORGER TX
79007-6318
US

IV. Provider business mailing address

1506 BEDIVERE ST
BORGER TX
79007-6318
US

V. Phone/Fax

Practice location:
  • Phone: 806-223-5305
  • Fax:
Mailing address:
  • Phone: 806-223-5305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number200077
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number200077
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: