Provider Demographics
NPI:1639953433
Name:CLARK, BETHANY KRISTIN (FNP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:KRISTIN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 PARK SHADOW CT
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3266
Mailing Address - Country:US
Mailing Address - Phone:626-589-0481
Mailing Address - Fax:
Practice Address - Street 1:706 PARK SHADOW CT
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3266
Practice Address - Country:US
Practice Address - Phone:626-589-0481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily