Provider Demographics
NPI:1851572804
Name:CLARK, INGRIS ISABEL
Entity Type:Individual
Prefix:MRS
First Name:INGRIS
Middle Name:ISABEL
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 1:4065 COUNTY CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3410
Mailing Address - Country:US
Mailing Address - Phone:951-358-5438
Mailing Address - Fax:951-358-5019
Practice Address - Street 1:5256 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:RUBIDOUX
Practice Address - State:CA
Practice Address - Zip Code:92509-4624
Practice Address - Country:US
Practice Address - Phone:951-955-5333
Practice Address - Fax:951-955-5329
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide