Provider Demographics
NPI:1538657465
Name:CLARK, NICHOLAS (LPN)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 CITY VIEW DR STE 206
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5326
Mailing Address - Country:US
Mailing Address - Phone:307-789-7915
Mailing Address - Fax:
Practice Address - Street 1:350 CITY VIEW DR STE 206
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8096164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse