Provider Demographics
NPI:1700251295
Name:CLARK, BAYLIE (ATS)
Entity Type:Individual
Prefix:
First Name:BAYLIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12381 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9576
Mailing Address - Country:US
Mailing Address - Phone:320-905-4477
Mailing Address - Fax:
Practice Address - Street 1:12381 N SHORE DR
Practice Address - Street 2:
Practice Address - City:SPICER
Practice Address - State:MN
Practice Address - Zip Code:56288-9576
Practice Address - Country:US
Practice Address - Phone:320-905-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program