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General NPI Number Information
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NPI Number | 1093377905
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Entity Type | Individual
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Provider Name | NICHOLE N CLARK APNP
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Gender | Female
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Dates
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Enumeration Date | 07/01/2019
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Last Update Date | 12/14/2023
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Provider Practice Location Address
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Address Line | 633 RIDGEVIEW DR
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City | MCHENRY
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State | IL
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Zip | 60050-7012
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Country | US
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Telephone | 815-344-0621
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Fax | 815-344-0664
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Provider Business Mailing Address
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Address Line | 29373 NETWORK PL
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City | CHICAGO
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State | IL
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Zip | 60673-2334
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Country | US
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Telephone | 847-390-5900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 10067
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209019549
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License Number State | IL
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