Basic Information
| Provider Information | |||||||||
| NPI: | 1699365601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLACK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PNP (C) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3153 ROLLINGS AVE | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913606433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059903730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2021 | ||||||||
| LastUpdateDate: | 01/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 95015295 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.