Provider Demographics
NPI:1417784406
Name:CLEM, NICOLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:CLEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:IL
Mailing Address - Zip Code:61849-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 W 1ST SREET
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:IL
Practice Address - Zip Code:61849-1215
Practice Address - Country:US
Practice Address - Phone:217-896-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist