Provider Demographics
NPI:1447248760
Name:CLARK, CORYN B (NP)
Entity type:Individual
Prefix:MS
First Name:CORYN
Middle Name:B
Last Name:CLARK
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Gender:F
Credentials:NP
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Mailing Address - Street 1:234 GLENBROOK RD UNIT 4011
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06269-4011
Mailing Address - Country:US
Mailing Address - Phone:860-486-4700
Mailing Address - Fax:860-486-1765
Practice Address - Street 1:234 GLENBROOK RD UNIT 4011
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06269-4011
Practice Address - Country:US
Practice Address - Phone:860-486-4700
Practice Address - Fax:860-486-1765
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-12-05
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Provider Licenses
StateLicense IDTaxonomies
CT001316364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P05800Medicare UPIN