Provider Demographics
NPI:1578951752
Name:CLARK, JANEL L (FNP)
Entity type:Individual
Prefix:
First Name:JANEL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JANEL
Other - Middle Name:L
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2166 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4700
Mailing Address - Country:US
Mailing Address - Phone:618-452-4969
Mailing Address - Fax:618-451-7115
Practice Address - Street 1:2166 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4700
Practice Address - Country:US
Practice Address - Phone:618-452-4969
Practice Address - Fax:618-451-7115
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014043297363LF0000X
IL209015955363LP0808X
IL309.012399363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health