Provider Demographics
NPI:1184619595
Name:CLARK, ELISE DIANE (FNP BC)
Entity type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2510
Mailing Address - Country:US
Mailing Address - Phone:419-991-7805
Mailing Address - Fax:419-991-7862
Practice Address - Street 1:2875 W ELM ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2510
Practice Address - Country:US
Practice Address - Phone:419-991-7805
Practice Address - Fax:419-991-7862
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP06689363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934001OtherMEDICARE PTAN
OH2360252Medicaid
OH500023896OtherTRAVELERS/RAILROAD MEDICA
CLNP09062Medicare ID - Type Unspecified
OH2360252Medicaid