Healthcare Provider Details

I. General information

NPI: 1396004776
Provider Name (Legal Business Name): ILLISE CLARK FNP-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 SCHAEFFER ST
MENTOR OH
44060-5035
US

IV. Provider business mailing address

8881 SCHAEFFER ST
MENTOR OH
44060-5035
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-9309
  • Fax:
Mailing address:
  • Phone: 440-255-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.371331
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0022454
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: