Provider Demographics
NPI:1033320965
Name:CLARK, MARY S (RD, CDE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-6623
Mailing Address - Country:US
Mailing Address - Phone:360-424-6250
Mailing Address - Fax:
Practice Address - Street 1:2000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-4327
Practice Address - Country:US
Practice Address - Phone:360-856-6021
Practice Address - Fax:360-856-7300
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000724133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered