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NPI Code Detail

MEDICARE: SHELLEY L CLARK NP

MEDICARE: SHELLEY L CLARK NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner71004374AIN

General Provider Information

NPI Number : 1093158925
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHELLEY L CLARK NP
Provider Business Mailing Address
First Line : PO BOX 775383
Second Line :
City : CHICAGO
State : IL
Zip : 60677-5383
Country : US
Telephone Number : 812-376-5315
Fax Number :
Provider Business Practice Location Address
First Line : 815 SCHNIER ST
Second Line :
City : COLUMBUS
State : IN
Zip : 47201-2619
Country : US
Telephone Number : 812-376-5780
Fax Number : 812-376-5781
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/10/2013
Last Update Date : 09/06/2024

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