Provider Demographics
NPI:1093481772
Name:CLERK, GRACE ENU (NP)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ENU
Last Name:CLERK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:35237 YUCAIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4340
Mailing Address - Country:US
Mailing Address - Phone:909-790-6200
Mailing Address - Fax:909-790-6220
Practice Address - Street 1:35237 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4340
Practice Address - Country:US
Practice Address - Phone:909-790-6200
Practice Address - Fax:909-790-6220
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95016640363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner