Provider Demographics
NPI:1326572132
Name:CLARK, JUANETTE G (FNP)
Entity Type:Individual
Prefix:DR
First Name:JUANETTE
Middle Name:G
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:DR
Other - First Name:JUANETTE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:683 LOMAS SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1412
Mailing Address - Country:US
Mailing Address - Phone:858-755-6697
Mailing Address - Fax:
Practice Address - Street 1:27168 NEWPORT RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-7383
Practice Address - Country:US
Practice Address - Phone:951-246-3033
Practice Address - Fax:951-246-7373
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002760363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care