Provider Demographics
NPI:1346519196
Name:CLARK, AMY E (NY 016459)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:NY 016459
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1507
Mailing Address - Country:US
Mailing Address - Phone:607-324-0640
Mailing Address - Fax:607-324-1301
Practice Address - Street 1:71 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-1507
Practice Address - Country:US
Practice Address - Phone:607-324-0640
Practice Address - Fax:607-324-1301
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016459251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016459Medicaid