Healthcare Provider Details

I. General information

NPI: 1467385559
Provider Name (Legal Business Name): MAURISA LORRENE CLARK-HALLUMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3740
US

IV. Provider business mailing address

8525 TOBIAS AVE APT 216
PANORAMA CITY CA
91402-2958
US

V. Phone/Fax

Practice location:
  • Phone: 818-212-6742
  • Fax:
Mailing address:
  • Phone: 818-212-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number748566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: