Healthcare Provider Details

I. General information

NPI: 1669734778
Provider Name (Legal Business Name): CORINA CLARK-DERMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SAN PABLO AVE
ALBANY CA
94706-1103
US

IV. Provider business mailing address

3687 MT DIABLO BLVD S
LAFAYETTE CA
94549-3717
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21609
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number772499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: