Provider Demographics
NPI:1700194172
Name:CLARK, TAYLOR REBECCA (NP)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:REBECCA
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:REBECCA
Other - Last Name:WANGGAARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PNP
Mailing Address - Street 1:11 PARK PLACE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007
Mailing Address - Country:US
Mailing Address - Phone:212-226-7666
Mailing Address - Fax:212-202-7988
Practice Address - Street 1:15 WARREN ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007
Practice Address - Country:US
Practice Address - Phone:212-226-7666
Practice Address - Fax:212-202-7988
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382160363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics