1093377905 NPI number — NICHOLE N CLARK APNP

Table of content: NICHOLE N CLARK APNP (NPI 1093377905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093377905 NPI number — NICHOLE N CLARK APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
NICHOLE
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093377905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29373 NETWORK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-2334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-390-5900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 RIDGEVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-7012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-344-0621
Provider Business Practice Location Address Fax Number:
815-344-0664
Provider Enumeration Date:
07/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  10067 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 209019549 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1093377905 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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