Provider Demographics
NPI:1235785809
Name:CLARK, SHAMMONA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHAMMONA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S MICHIGAN AVE
Mailing Address - Street 2:STE LLD
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616
Mailing Address - Country:US
Mailing Address - Phone:312-866-4642
Mailing Address - Fax:
Practice Address - Street 1:2600 S MICHIGAN AVE
Practice Address - Street 2:STE LLD
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3512
Practice Address - Country:US
Practice Address - Phone:312-866-4642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020109363LF0000X
IL041410185163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0600XNursing Service ProvidersRegistered NurseGerontology