Healthcare Provider Details

I. General information

NPI: 1760646970
Provider Name (Legal Business Name): DEBBIE CLARK TRACY FNP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W SAN BERNARDINO RD
COVINA CA
91723-1515
US

IV. Provider business mailing address

210 W SAN BERNARDINO RD
COVINA CA
91723-1515
US

V. Phone/Fax

Practice location:
  • Phone: 626-938-7586
  • Fax:
Mailing address:
  • Phone: 626-938-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17135
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number2077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: