Provider Demographics
NPI:1902699499
Name:CLARK, NICOLE (LDO)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8137 REDBUD VINE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89085-4456
Mailing Address - Country:US
Mailing Address - Phone:707-758-3386
Mailing Address - Fax:
Practice Address - Street 1:3950 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4895
Practice Address - Country:US
Practice Address - Phone:702-631-8472
Practice Address - Fax:702-631-9417
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV527156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician