MEDICARE: MRS. LEANN CLARK RN

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
1	363LF0000X	Family Nurse Practitioner	1001317	TX

General Provider Information

NPI Number	:	1336952100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEANN CLARK RN

Provider Business Mailing Address
First Line	:	7104 CANISIUS CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-1382
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8611 HILLCREST AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-4203
Country	:	US
Telephone Number	:	214-645-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	02/02/2026

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