Provider Demographics
NPI:1083110225
Name:CLARK, NICOLE C (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:C
Other - Last Name:SCHMITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 300
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8622
Practice Address - Country:US
Practice Address - Phone:765-485-8649
Practice Address - Fax:765-485-8650
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006481A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014551Medicaid