Healthcare Provider Details

I. General information

NPI: 1124487509
Provider Name (Legal Business Name): NICOLA MARIE CLARKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 HIGHWAY 160 W
FORT MILL SC
29708-8025
US

IV. Provider business mailing address

1740 HIGHWAY 160 W
FORT MILL SC
29708-8025
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29981
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015982
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5023642
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: