Provider Demographics
NPI:1033788187
Name:CLARK, KIMBERLY CORPUZ-AGBALOG (LVN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CORPUZ-AGBALOG
Last Name:CLARK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:CORPUZ
Other - Last Name:AGBALOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:14410 MULBERRY DR APT 113
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90604-1398
Mailing Address - Country:US
Mailing Address - Phone:562-673-3176
Mailing Address - Fax:
Practice Address - Street 1:1825 E THELBORN ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1442
Practice Address - Country:US
Practice Address - Phone:626-915-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250826164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse