Provider Demographics
NPI:1962885145
Name:CLARK, ELISE N (FNP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:N
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5473 BLAIR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4227
Mailing Address - Country:US
Mailing Address - Phone:972-850-0687
Mailing Address - Fax:
Practice Address - Street 1:5473 BLAIR RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4227
Practice Address - Country:US
Practice Address - Phone:972-850-0687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128458363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3502510-02Medicaid
TX433090YNQJMedicare Oscar/Certification