Healthcare Provider Details

I. General information

NPI: 1679775274
Provider Name (Legal Business Name): NEKOLE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 9TH ST
SAN FRANCISCO CA
94103-2603
US

IV. Provider business mailing address

170 9TH ST
SAN FRANCISCO CA
94103-2603
US

V. Phone/Fax

Practice location:
  • Phone: 415-777-0333
  • Fax: 415-864-4042
Mailing address:
  • Phone: 451-972-0866
  • Fax: 415-864-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: