Provider Demographics
NPI:1215489307
Name:CLARK, KELSEY ANN (RVT, RDCS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RVT, RDCS
Other - Prefix:MRS
Other - First Name:KELSEY
Other - Middle Name:CLARK
Other - Last Name:COSSUTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13 INDIAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-4614
Mailing Address - Country:US
Mailing Address - Phone:603-770-7299
Mailing Address - Fax:
Practice Address - Street 1:13 INDIAN RIDGE RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-4614
Practice Address - Country:US
Practice Address - Phone:603-770-7299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT168132246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography