Provider Demographics
NPI:1790166775
Name:CLARK, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 CLARK RD
Mailing Address - Street 2:SUITE W
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-4856
Mailing Address - Country:US
Mailing Address - Phone:530-872-6328
Mailing Address - Fax:530-872-6364
Practice Address - Street 1:5910 CLARK RD
Practice Address - Street 2:SUITE W
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-4856
Practice Address - Country:US
Practice Address - Phone:530-872-6328
Practice Address - Fax:530-872-6364
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225925164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse