Provider Demographics
NPI:1073857801
Name:CLARK, LISA ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CHENANGO ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-1668
Mailing Address - Country:US
Mailing Address - Phone:607-221-5041
Mailing Address - Fax:
Practice Address - Street 1:1110 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1668
Practice Address - Country:US
Practice Address - Phone:607-221-5041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016722-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist