Provider Demographics
NPI:1578012514
Name:CLARK, DEANNA (RN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:THAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1539 STONE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-1516
Mailing Address - Country:US
Mailing Address - Phone:585-794-8283
Mailing Address - Fax:
Practice Address - Street 1:1539 STONE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615-1516
Practice Address - Country:US
Practice Address - Phone:585-794-8283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY577506163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse