Provider Demographics
NPI:1619370194
Name:CLARK, MARIAM (NP)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 HARRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-7376
Mailing Address - Country:US
Mailing Address - Phone:909-613-9238
Mailing Address - Fax:
Practice Address - Street 1:3612 1/2 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2326
Practice Address - Country:US
Practice Address - Phone:323-264-7796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF0714462363LF0000X
CA95000880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily