Provider Demographics
NPI:1205823093
Name:CLARK, HOLLY A (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9024 KINSALE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-3899
Mailing Address - Country:US
Mailing Address - Phone:708-308-6993
Mailing Address - Fax:
Practice Address - Street 1:14315 108TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5700
Practice Address - Country:US
Practice Address - Phone:815-300-7764
Practice Address - Fax:708-385-8780
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309-001914363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner