Provider Demographics
NPI:1346906385
Name:CLARK, NICHOLAS (RN)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 MONTEREY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4090
Mailing Address - Country:US
Mailing Address - Phone:567-207-8646
Mailing Address - Fax:
Practice Address - Street 1:1538 MONTEREY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4090
Practice Address - Country:US
Practice Address - Phone:567-207-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA728326163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse