Healthcare Provider Details

I. General information

NPI: 1528217197
Provider Name (Legal Business Name): HEATHER CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 POST ST
SAN FRANCISCO CA
94109-6703
US

IV. Provider business mailing address

245 17TH AVE
SAN FRANCISCO CA
94121-2310
US

V. Phone/Fax

Practice location:
  • Phone: 415-474-7310
  • Fax:
Mailing address:
  • Phone: 415-515-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: