Provider Demographics
NPI:1881574382
Name:CLARK, KHYRISTIENNE
Entity type:Individual
Prefix:
First Name:KHYRISTIENNE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9636 S HARVARD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3814
Mailing Address - Country:US
Mailing Address - Phone:747-295-3999
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD BLDG 304
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156FX1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Single Specialty