Provider Demographics
NPI:1588234785
Name:CLARK, KYLIE RAE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:RAE
Other - Last Name:RIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4110 ALANA CIR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3440
Mailing Address - Country:US
Mailing Address - Phone:949-293-8821
Mailing Address - Fax:
Practice Address - Street 1:1738 S TREMONT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5309
Practice Address - Country:US
Practice Address - Phone:760-439-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287452164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse