Healthcare Provider Details

I. General information

NPI: 1457791824
Provider Name (Legal Business Name): KANSAS MARIE ST CLAIR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 10/16/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 22ND ST
LUBBOCK TX
79410-1334
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 806-796-3000
  • Fax: 806-796-3006
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP123878
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number702520
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: