Healthcare Provider Details

I. General information

NPI: 1649196809
Provider Name (Legal Business Name): ASHLEY CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 STATE ST
WATERTOWN NY
13601-2839
US

IV. Provider business mailing address

324 COUNTY ROUTE 51 BLDG 1
MALONE NY
12953-4502
US

V. Phone/Fax

Practice location:
  • Phone: 315-755-1251
  • Fax: 315-291-6601
Mailing address:
  • Phone: 518-483-1251
  • Fax: 518-483-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: