Provider Demographics
NPI:1174344154
Name:SPELLMAN, CLINTON
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:SPELLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9516 APPALACHIAN DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1109
Mailing Address - Country:US
Mailing Address - Phone:916-612-7748
Mailing Address - Fax:
Practice Address - Street 1:3050 BEACON BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3467
Practice Address - Country:US
Practice Address - Phone:916-594-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker