Provider Demographics
NPI:1104832617
Name:CLARK, DONNA M (GNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10170 SORRENTO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1604
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:
Practice Address - Street 1:130 CEDAR RD STE 200
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5102
Practice Address - Country:US
Practice Address - Phone:760-806-5620
Practice Address - Fax:760-806-5639
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN485608163W00000X, 163WD0400X, 163WG0600X
CA6328363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN485608Medicaid
CAP09312Medicare UPIN
CARN485608Medicaid