Provider Demographics
NPI:1356154595
Name:LY, CLARENCE (NP)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:LY
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 W FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3785
Mailing Address - Country:US
Mailing Address - Phone:909-982-8944
Mailing Address - Fax:
Practice Address - Street 1:914 W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3785
Practice Address - Country:US
Practice Address - Phone:909-982-8944
Practice Address - Fax:909-985-0932
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95031960363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner