Basic Information
Provider Information
NPI: 1447496898
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: TRACY
MiddleName: JILL
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 144 ACORN DR
Address2:  
City: SCOTIA
State: NY
PostalCode: 123024717
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 435 4TH ST
Address2:  
City: TROY
State: NY
PostalCode: 121805324
CountryCode: US
TelephoneNumber: 5182716777
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/06/2009
LastUpdateDate: 01/06/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X4769-1NYY Other Service ProvidersSpecialist 

No ID Information.


Home