Provider Demographics
NPI:1295222792
Name:CLARK, ALIA KEHAULANI
Entity type:Individual
Prefix:
First Name:ALIA
Middle Name:KEHAULANI
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 1:1135 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3323
Mailing Address - Country:US
Mailing Address - Phone:805-465-9847
Mailing Address - Fax:805-666-1029
Practice Address - Street 1:1135 MARSH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3323
Practice Address - Country:US
Practice Address - Phone:805-465-9847
Practice Address - Fax:805-666-1029
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA533176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA533OtherLICENSED MIDWIFE