Healthcare Provider Details

I. General information

NPI: 1205654878
Provider Name (Legal Business Name): AMANDA NICHOLE CLARK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 RIVERY BLVD
GEORGETOWN TX
78628-3058
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 512-509-9550
  • Fax: 512-509-9555
Mailing address:
  • Phone: 800-994-0371
  • Fax: 254-215-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209030659
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1215968
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.030659
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: