Provider Demographics
NPI:1821055724
Name:CLARK, NICOLE GINETTE (MSPT, PHD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GINETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSPT, PHD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:GINETTE
Other - Last Name:MORIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:1004 PROGRESS DR STE 100
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-6323
Practice Address - Country:US
Practice Address - Phone:913-351-3586
Practice Address - Fax:913-351-3939
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22938225100000X
FLPT22633225100000X
KS11-06834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist