Provider Demographics
NPI:1912464587
Name:BARK, THERESA (FNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3066
Mailing Address - Country:US
Mailing Address - Phone:909-525-8868
Mailing Address - Fax:
Practice Address - Street 1:445 S ASSOCIATED RD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5802
Practice Address - Country:US
Practice Address - Phone:714-494-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily