Provider Demographics
NPI:1083300727
Name:CLARKE, DEVIAN
Entity Type:Individual
Prefix:
First Name:DEVIAN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11783 BRUSH HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-5711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11783 BRUSH HOLLOW LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-5711
Practice Address - Country:US
Practice Address - Phone:909-553-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95335693163W00000X
CA287721164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse