Healthcare Provider Details

I. General information

NPI: 1609748276
Provider Name (Legal Business Name): TINA MARIE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N PINES RD
SPOKANE VALLEY WA
99206-4939
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 509-893-8140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP.AP.70120514-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: