Erica Dominique Clack

Key facts

NPI

1639734502

Entity type

Individual (NPI type 1)

Primary specialty

Licensed Vocational Nurse 164X00000X

License

319226 (TX)

Practice address

406 E Planters St
San Augustine, TX 75972-2140

Phone

(936) 201-2132

NPI assigned

May 7, 2019

Sex

Female

Sole proprietor

No

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 7, 2019.

{
    "created_epoch": "1557187200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1557187200000",
    "number": "1639734502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "406 E PLANTERS ST",
            "city": "SAN AUGUSTINE",
            "state": "TX",
            "postal_code": "759722140",
            "telephone_number": "936-201-2132"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "406 E PLANTERS ST",
            "city": "SAN AUGUSTINE",
            "state": "TX",
            "postal_code": "759722140",
            "telephone_number": "936-201-2132"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLACK",
        "first_name": "ERICA",
        "middle_name": "DOMINIQUE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-05-07",
        "last_updated": "2019-05-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "164X00000X",
            "taxonomy_group": "",
            "desc": "Licensed Vocational Nurse",
            "state": "TX",
            "license": "319226",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in San Augustine, TX · Licensed Vocational Nurse in Texas