Provider Demographics
NPI:1083774582
Name:CLARK, KATHLEEN MARIE (MSN FNP C)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3247 CHATWIN AVE
Mailing Address - Street 2:SHS
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808
Mailing Address - Country:US
Mailing Address - Phone:562-354-6083
Mailing Address - Fax:
Practice Address - Street 1:1250 BELLFLOWER BLVD
Practice Address - Street 2:SHS
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90840-0201
Practice Address - Country:US
Practice Address - Phone:562-985-5146
Practice Address - Fax:562-985-8404
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16395363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner