Healthcare Provider Details

I. General information

NPI: 1639953433
Provider Name (Legal Business Name): BETHANY KRISTIN CLARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LAGUNA RD STE 200
FULLERTON CA
92835-3601
US

IV. Provider business mailing address

706 PARK SHADOW CT
BALDWIN PARK CA
91706-3266
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-5350
  • Fax: 714-446-5539
Mailing address:
  • Phone: 626-589-0481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: