Provider Demographics
NPI:1003630666
Name:CLARK, DIANA STEPHANIE (IBCLC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:STEPHANIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:STEPHANIE
Other - Last Name:ORELLANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBCLC
Mailing Address - Street 1:28 MOUNTAIN LAUREL WAY
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-6264
Mailing Address - Country:US
Mailing Address - Phone:626-222-4614
Mailing Address - Fax:
Practice Address - Street 1:28 MOUNTAIN LAUREL WAY
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-6264
Practice Address - Country:US
Practice Address - Phone:626-222-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11137880174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144749391OtherTHE LACTATION NETWORK