Provider Demographics
NPI:1720606130
Name:CLARK, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 BUNKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-5539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10455 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7046
Practice Address - Country:US
Practice Address - Phone:814-623-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0031682363A00000X
PAMA061686208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant