Healthcare Provider Details

I. General information

NPI: 1871968768
Provider Name (Legal Business Name): NICOLE CLARK LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 WILSON DR
BLOOMFIELD IN
47424-1054
US

IV. Provider business mailing address

332 WILSON DR
BLOOMFIELD IN
47424-1054
US

V. Phone/Fax

Practice location:
  • Phone: 317-432-3861
  • Fax:
Mailing address:
  • Phone: 317-432-3861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001806A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: