Provider Demographics
NPI:1699553909
Name:CLARK, ELYSE MARTEAL
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:MARTEAL
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5317 E CALDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2926
Mailing Address - Country:US
Mailing Address - Phone:562-485-7335
Mailing Address - Fax:
Practice Address - Street 1:200 PINE AVE STE 400
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-3039
Practice Address - Country:US
Practice Address - Phone:562-285-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program