Provider Demographics
NPI:1811937790
Name:CLEMENT, AMY N (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:N
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIDDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-3242
Mailing Address - Country:US
Mailing Address - Phone:860-828-6671
Mailing Address - Fax:
Practice Address - Street 1:4 HAZEL AVE
Practice Address - Street 2:GLENDALE CENTER
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4706
Practice Address - Country:US
Practice Address - Phone:203-723-1456
Practice Address - Fax:203-723-0242
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001828363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004200218Medicaid
CT500001835Medicare PIN
CT004200218Medicaid