1164007563 NPI number — MRS. SAMANTHA MARY-KATHLEEN CLEMONS FNP-C

Table of content: MRS. SAMANTHA MARY-KATHLEEN CLEMONS FNP-C (NPI 1164007563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164007563 NPI number — MRS. SAMANTHA MARY-KATHLEEN CLEMONS FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMONS
Provider First Name:
SAMANTHA
Provider Middle Name:
MARY-KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164007563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 S LOOP 336 W STE 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-3737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-235-2825
Provider Business Mailing Address Fax Number:
936-235-2826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 S LOOP 336 W STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304-3737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
369-235-2825
Provider Business Practice Location Address Fax Number:
936-235-2826
Provider Enumeration Date:
03/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1032185 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com