Provider Demographics
NPI:1023405222
Name:CLEM, NICOLE ANNE (ARNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:CLEM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 CREIGHTON RD
Mailing Address - Street 2:STE 1
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7152
Mailing Address - Country:US
Mailing Address - Phone:850-444-4700
Mailing Address - Fax:850-444-7497
Practice Address - Street 1:1619 CREIGHTON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7152
Practice Address - Country:US
Practice Address - Phone:850-444-4700
Practice Address - Fax:850-444-7497
Is Sole Proprietor?:No
Enumeration Date:2015-04-25
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9409592363L00000X
AL1-133121363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016992700Medicaid
FL13548879OtherCAQH
FLQ3K4TOtherBCBSFL
FLQ3K4TOtherBCBSFL