Basic Information
| Provider Information | |||||||||
| NPI: | 1104832617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10170 SORRENTO VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 CEDAR RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920835102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608065620 | ||||||||
| FaxNumber: | 7608065639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN485608 | CA | N | Nursing Service Providers | Registered Nurse | 163WD0400X | RN485608 | CA | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 163WG0600X | RN485608 | CA | N | Nursing Service Providers | Registered Nurse | Gerontology | 363LG0600X | 6328 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | RN485608 | 05 | CA | MEDICAID |