Provider Demographics
NPI:1033464383
Name:CLARK, KERRIE LYNNE (MSED)
Entity Type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:LYNNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1324
Mailing Address - Country:US
Mailing Address - Phone:631-957-2242
Mailing Address - Fax:
Practice Address - Street 1:51 3RD ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1324
Practice Address - Country:US
Practice Address - Phone:631-957-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1825979174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist