Healthcare Provider Details

I. General information

NPI: 1023151594
Provider Name (Legal Business Name): CALLANDRA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20420 VICTORY CT
SANTA CLARITA CA
91350-8531
US

IV. Provider business mailing address

20420 VICTORY CT
SANTA CLARITA CA
91350-8531
US

V. Phone/Fax

Practice location:
  • Phone: 661-252-8987
  • Fax: 661-252-8987
Mailing address:
  • Phone: 661-252-8987
  • Fax: 661-252-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1713
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number669232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: