Healthcare Provider Details

I. General information

NPI: 1285322016
Provider Name (Legal Business Name): ANTONIA MALIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

IV. Provider business mailing address

285 MANZANITA DR
OCEANSIDE CA
92057-5405
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-3400
  • Fax:
Mailing address:
  • Phone: 619-621-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number95191828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: