Provider Demographics
NPI:1477052157
Name:CLARK, THAYER A (DNP)
Entity Type:Individual
Prefix:DR
First Name:THAYER
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ESSEX LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-2600
Mailing Address - Country:US
Mailing Address - Phone:203-232-2017
Mailing Address - Fax:
Practice Address - Street 1:76 WATERTOWN RD STE 2F
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:CT
Practice Address - Zip Code:06787-1826
Practice Address - Country:US
Practice Address - Phone:860-880-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7667363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT$$$$$$$$$Medicaid