Healthcare Provider Details

I. General information

NPI: 1881531192
Provider Name (Legal Business Name): ALEXIS NICOLE CLARK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11483 ARIZONA AVE
RIVERSIDE CA
92503-5817
US

IV. Provider business mailing address

11483 ARIZONA AVE
RIVERSIDE CA
92503-5817
US

V. Phone/Fax

Practice location:
  • Phone: 714-932-5273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: