Provider Demographics
NPI:1013393487
Name:CLARK, AYLAH (ND)
Entity Type:Individual
Prefix:
First Name:AYLAH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SIMSBURY RD
Mailing Address - Street 2:209
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SIMSBURY RD
Practice Address - Street 2:209
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3793
Practice Address - Country:US
Practice Address - Phone:860-674-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5.000540175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath