Provider Demographics
NPI:1790256725
Name:CLARK, KAYLA NICOLE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:NICOLE
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 1:3433 W SHAW AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-476-2115
Mailing Address - Fax:
Practice Address - Street 1:3433 W SHAW AVE STE 107
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3229
Practice Address - Country:US
Practice Address - Phone:559-476-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
CA171M00000X
CAMPSS-NRETPW175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist