Provider Demographics
NPI:1134683709
Name:CLARK, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 ASPEN LEAF DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-6037
Mailing Address - Country:US
Mailing Address - Phone:850-748-6605
Mailing Address - Fax:
Practice Address - Street 1:915 W MONROE ST STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-486-2314
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN82973163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator