Provider Demographics
NPI:1033845037
Name:CLARK, KARLA G (RDN,LD)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:G
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42044-8697
Mailing Address - Country:US
Mailing Address - Phone:270-703-9839
Mailing Address - Fax:
Practice Address - Street 1:28 CHICK ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered