Provider Demographics
NPI:1316687650
Name:CLARK, TIMETRA DIANE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TIMETRA
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 1:1401 E 55TH ST APT 905N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5468
Mailing Address - Country:US
Mailing Address - Phone:708-759-3112
Mailing Address - Fax:
Practice Address - Street 1:1401 E 55TH ST APT 905N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5468
Practice Address - Country:US
Practice Address - Phone:708-759-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041436444163WN0300X
FL9562544163WN0300X
IL209024791363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0300XNursing Service ProvidersRegistered NurseNephrology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner