Provider Demographics
NPI:1730228388
Name:CLARKE, MAR KESHIA (NP)
Entity type:Individual
Prefix:
First Name:MAR KESHIA
Middle Name:
Last Name:CLARKE
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 1:21311 MADRONA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5970
Mailing Address - Country:US
Mailing Address - Phone:866-909-3627
Mailing Address - Fax:
Practice Address - Street 1:12618 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3907
Practice Address - Country:US
Practice Address - Phone:310-263-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15097363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner