Healthcare Provider Details

I. General information

NPI: 1316687650
Provider Name (Legal Business Name): TIMETRA DIANE CLARK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 55TH ST APT 905N
CHICAGO IL
60615-5468
US

IV. Provider business mailing address

1401 E 55TH ST APT 905N
CHICAGO IL
60615-5468
US

V. Phone/Fax

Practice location:
  • Phone: 708-759-3112
  • Fax:
Mailing address:
  • Phone: 708-759-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209024791
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024791
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License Number041436444
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License Number9562544
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: