Provider Demographics
NPI:1326734948
Name:CLARK, KRISTEN MARIE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 DECROS PT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1949
Mailing Address - Country:US
Mailing Address - Phone:281-224-1500
Mailing Address - Fax:
Practice Address - Street 1:7600 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1906
Practice Address - Country:US
Practice Address - Phone:713-790-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-188505163W00000X, 163WN0002X
TX1181713363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care