1649727199 NPI number — MRS. BRITTANI JOLAI CLARK CPNP-PC

Table of content: MRS. BRITTANI JOLAI CLARK CPNP-PC (NPI 1649727199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649727199 NPI number — MRS. BRITTANI JOLAI CLARK CPNP-PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
BRITTANI
Provider Middle Name:
JOLAI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPNP-PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCULLOUGH
Provider Other First Name:
BRITTANI
Provider Other Middle Name:
JOLAI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649727199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28847 W HILLS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALENCIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91354-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-283-7146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1172 N MACLAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FERNANDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91340-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-898-1388
Provider Business Practice Location Address Fax Number:
818-270-9590
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  95004797 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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