Provider Demographics
NPI:1518234327
Name:CLARK, LESLIE ERIN (RN, NP)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ERIN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39865 CEDAR BLVD
Mailing Address - Street 2:343
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5352
Mailing Address - Country:US
Mailing Address - Phone:510-449-5298
Mailing Address - Fax:
Practice Address - Street 1:5671 SANTA TERESA BLVD
Practice Address - Street 2:105
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-6512
Practice Address - Country:US
Practice Address - Phone:408-284-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA589440163W00000X
CA20397164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse