Provider Demographics
NPI:1518637180
Name:CLARK, KAITLYN NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 DOVERGLEN WAY
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-5819
Mailing Address - Country:US
Mailing Address - Phone:626-224-4688
Mailing Address - Fax:
Practice Address - Street 1:14442 WHITTIER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-2162
Practice Address - Country:US
Practice Address - Phone:562-945-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA60040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant