45D1011714 CLIA NUMBER - SOUTH POLK MEDICAL CLINIC GWENITA ROBERTS FNP C

Laboratory Demographics

CLIA Number: 45D1011714

Facility Name: SOUTH POLK MEDICAL CLINIC GWENITA ROBERTS FNP C

Facility Address:
3436 SOUTH POLK STREET
DALLAS, TX
ZIP 75224
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Facility Phone Number: 214 372-9200

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1043351760

Taxonomy: 363L00000X - Nurse Practitioner
(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision making and direct accountability for clinical judgment across the health care continuum or in a certified specialty. (2) A registered nurse who has completed additional training beyond basic nursing education and who provides primary health care services in accordance with state nurse practice laws or statutes. Tasks performed by nurse practitioners vary with practice requirements mandated by geographic, political, economic, and social factors. Nurse practitioner specialists include, but are not limited to, family nurse practitioners, gerontological nurse practitioners, pediatric nurse practitioners, obstetric-gynecologic nurse practitioners, and school nurse practitioners.

CLIA Record

Field Name	Field Value
CLIA Number	45D1011714
LAB Type	Practitioner Other
Facility Name	SOUTH POLK MEDICAL CLINIC GWENITA ROBERTS FNP C
Street	3436 SOUTH POLK STREET
City	DALLAS
State	TX
ZIP	75224
Phone	214 372-9200
CertificateType	4
CertificateEffectiveDate	4/22/2023
CertificateExpirationDate	4/21/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024