Provider Demographics
NPI:1851644215
Name:CLARK, REBEKAH ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:REBEKAH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:REBEKAH
Other - Middle Name:ANN
Other - Last Name:BLOOMFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1421 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8505
Mailing Address - Country:US
Mailing Address - Phone:714-633-6373
Mailing Address - Fax:
Practice Address - Street 1:700 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-3425
Practice Address - Country:US
Practice Address - Phone:714-633-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily