Provider Demographics
NPI:1912141656
Name:CLARK, NIKOL ANGEL (LAC)
Entity Type:Individual
Prefix:
First Name:NIKOL
Middle Name:ANGEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:102 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2235
Mailing Address - Country:US
Mailing Address - Phone:406-270-9356
Mailing Address - Fax:
Practice Address - Street 1:102 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2235
Practice Address - Country:US
Practice Address - Phone:406-270-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT232171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist