MEDICARE: CANDICE CLARK FNP-C

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	AP132130	TX

General Provider Information

NPI Number	:	1760932537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDICE CLARK FNP-C

Provider Business Mailing Address
First Line	:	25410 CHINA SPGS
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77373-8279
Country	:	US
Telephone Number	:	832-527-2999
Fax Number	:

Provider Business Practice Location Address
First Line	:	2617 W HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1757
Country	:	US
Telephone Number	:	832-831-7438
Fax Number	:

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

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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