Healthcare Provider Details

I. General information

NPI: 1053233148
Provider Name (Legal Business Name): NINA CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 LONG POND RD STE 303
ROCHESTER NY
14626-4135
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7778
  • Fax: 585-723-7925
Mailing address:
  • Phone:
  • Fax: 585-922-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360222
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: