Provider Demographics
NPI:1285866939
Name:CLARK, CELESTE (RN)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 BRONDSBURY LN
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4087
Mailing Address - Country:US
Mailing Address - Phone:916-561-7520
Mailing Address - Fax:
Practice Address - Street 1:5342 DUDLEY BLVD # 98
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1012
Practice Address - Country:US
Practice Address - Phone:916-561-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN146571163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management