Healthcare Provider Details

I. General information

NPI: 1790662336
Provider Name (Legal Business Name): VANESSA AGBOLI CLARKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VANESSA AGBOLI NP

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6248 66TH AVE
SACRAMENTO CA
95823-2733
US

IV. Provider business mailing address

3020 JUBILEE LN
FAIRFIELD CA
94533-7127
US

V. Phone/Fax

Practice location:
  • Phone: 707-301-7744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95141638
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95035223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: