Provider Demographics
NPI:1487091450
Name:CLARKSON, LILY N (FNP)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:N
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6240
Mailing Address - Fax:209-754-6274
Practice Address - Street 1:1113 HWY 49
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-755-1400
Practice Address - Fax:209-755-1430
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7118363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner