Provider Demographics
NPI:1205191475
Name:CLARK, CHARISMA MARIE (LVN)
Entity Type:Individual
Prefix:MISS
First Name:CHARISMA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 KATELLA AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3592
Mailing Address - Country:US
Mailing Address - Phone:714-503-6850
Mailing Address - Fax:
Practice Address - Street 1:4281 KATELLA AVE STE 120
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3592
Practice Address - Country:US
Practice Address - Phone:714-503-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN209103164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse