Provider Demographics
NPI:1447869029
Name:CLACK-WILSON, DESERIE ALINE
Entity type:Individual
Prefix:
First Name:DESERIE
Middle Name:ALINE
Last Name:CLACK-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LAFAYETTE BLVD STE 1128
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4725
Mailing Address - Country:US
Mailing Address - Phone:203-683-3428
Mailing Address - Fax:203-683-5901
Practice Address - Street 1:1000 LAFAYETTE BLVD STE 1128
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4725
Practice Address - Country:US
Practice Address - Phone:203-683-3428
Practice Address - Fax:203-683-5901
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker