Provider Demographics
NPI:1750411948
Name:CLARK, TRACYE LYNN (LVN)
Entity type:Individual
Prefix:MISS
First Name:TRACYE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46100 PINE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-9740
Mailing Address - Country:US
Mailing Address - Phone:661-344-2424
Mailing Address - Fax:831-385-1588
Practice Address - Street 1:46100 PINE MEADOW DR
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-9740
Practice Address - Country:US
Practice Address - Phone:661-344-2424
Practice Address - Fax:831-385-1588
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186106164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASYC8060OtherSTAFFCODE