MEDICARE: NIKKI J CLARK FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1180324	TX
2	363L00000X	Nurse Practitioner	893588	MS
3	363LF0000X	Family Nurse Practitioner	893588	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043671696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKKI J CLARK FNP-BC

Provider Business Mailing Address
First Line	:	3520 NW CENTRE DR
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3612
Country	:	US
Telephone Number	:	701-364-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 NW CENTRE DR
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3612
Country	:	US
Telephone Number	:	701-364-4999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2016
Last Update Date	:	03/04/2026

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