Provider Demographics
NPI:1033605431
Name:CLARK, WHITNEY NICOLE (CNM)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 S KNOXVILLE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2609
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:1140 S KNOXVILLE AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2609
Practice Address - Country:US
Practice Address - Phone:419-394-7314
Practice Address - Fax:419-394-7313
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNM.019373367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0300634Medicaid