Individual
TANISHA TIANA CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
333 CHRISTIAN ST, WALLINGFORD, CT 06492-3818
(203) 697-2983
Mailing address
333 CHRISTIAN ST, WALLINGFORD, CT 06492-3818
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
54.001470
CT
2255A2300X
Athletic Trainer
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/05/2018
Last updated
02/15/2021
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