Provider Demographics
NPI:1366617425
Name:CLARK, DORLISHA (LVN)
Entity type:Individual
Prefix:MRS
First Name:DORLISHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E SERVICE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3783
Mailing Address - Country:US
Mailing Address - Phone:323-365-6256
Mailing Address - Fax:310-268-4948
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:310-268-4948
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 207910164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse