Provider Demographics
NPI:1477780658
Name:CLANCY, NORA (OD)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:
Last Name:CLANCY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2077
Mailing Address - Country:US
Mailing Address - Phone:248-620-1100
Mailing Address - Fax:248-620-1196
Practice Address - Street 1:7117 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2077
Practice Address - Country:US
Practice Address - Phone:248-620-1100
Practice Address - Fax:248-620-1196
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F36787OtherBLUE CROSS AND BLUE SHIELD
MIM41550002OtherMEDICARE PTAN