Individual
ILLISE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-NP
Contact information
Practice address
8881 SCHAEFFER ST, MENTOR, OH 44060-5035
(440) 255-9309
Mailing address
8881 SCHAEFFER ST, MENTOR, OH 44060-5035
(440) 255-9309
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
RN.371331
OH
363LF0000X
Family Nurse Practitioner
Primary
APRN.CNP.0022454
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0268768
—
OH
Enumeration date
05/07/2012
Last updated
05/12/2026
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