Provider Demographics
NPI:1013909050
Name:CLARK, TERRI PATRICE (CNM, PHD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:PATRICE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNM, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CANNON ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2512
Mailing Address - Country:US
Mailing Address - Phone:203-287-9055
Mailing Address - Fax:
Practice Address - Street 1:100 CHURCH ST S
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1703
Practice Address - Country:US
Practice Address - Phone:203-737-2546
Practice Address - Fax:203-785-6455
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000058176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM7M691Medicare ID - Type Unspecified