Individual
NICOLETTE M CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
17 DAVIS BLVD STE 308, TAMPA, FL 33606-3438
(813) 974-2201
Mailing address
17 DAVIS BLVD STE 308, TAMPA, FL 33606-3438
(813) 974-2201
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
57.251172
OH
2086S0129X
Vascular Surgery Physician
Primary
ME0180960
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
57.251172
TRAINING CERTIFICATE (MD)
OH
Enumeration date
04/20/2021
Last updated
06/01/2026
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