Provider Demographics
NPI:1689345506
Name:CLARK, NADIA SHANISE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NADIA
Middle Name:SHANISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:NADIA
Other - Middle Name:SHANISE
Other - Last Name:HINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 SEQUATCHIE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1269
Mailing Address - Country:US
Mailing Address - Phone:601-410-7189
Mailing Address - Fax:
Practice Address - Street 1:4297 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421
Practice Address - Country:US
Practice Address - Phone:601-943-5060
Practice Address - Fax:601-943-5888
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily