MEDICARE: NICHOLE DEANN CLARK FNP

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
1	363LF0000X	Family Nurse Practitioner	A01919	AR

General Provider Information

NPI Number	:	1548464936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE DEANN CLARK FNP

Provider Business Mailing Address
First Line	:	PO BOX 1333
Second Line	:
City	:	CLINTON
State	:	AR
Zip	:	72031
Country	:	US
Telephone Number	:	501-745-7161
Fax Number	:	501-745-8714

Provider Business Practice Location Address
First Line	:	145 SHAKERAG ROAD
Second Line	:
City	:	CLINTON
State	:	AR
Zip	:	72031-6657
Country	:	US
Telephone Number	:	501-745-7161
Fax Number	:	501-745-8714

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	11/04/2011

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