Provider Demographics
NPI:1285137588
Name:CLARK, CARRIE ANN (FNP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1115 JANIS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3635
Mailing Address - Country:US
Mailing Address - Phone:408-412-8100
Mailing Address - Fax:408-412-8499
Practice Address - Street 1:340 DARDANELLI LN STE 10
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1418
Practice Address - Country:US
Practice Address - Phone:408-412-8100
Practice Address - Fax:408-412-8499
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA2017026979364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2017026979OtherAMERICAN NURSE CREDENTIALING CENTER
CACA303447OtherMEDICARE PTAN