Provider Demographics
NPI:1437978616
Name:CLARK, COURTNEY ELLISSE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELLISSE
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 1:355 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1309
Mailing Address - Country:US
Mailing Address - Phone:760-698-7648
Mailing Address - Fax:
Practice Address - Street 1:47915 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program