Provider Demographics
NPI:1548464936
Name:CLARK, NICHOLE DEANN (FNP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DEANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1333
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031
Mailing Address - Country:US
Mailing Address - Phone:501-745-7161
Mailing Address - Fax:501-745-8714
Practice Address - Street 1:145 SHAKERAG ROAD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6657
Practice Address - Country:US
Practice Address - Phone:501-745-7161
Practice Address - Fax:501-745-8714
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily