Provider Demographics
NPI:1073048567
Name:CLARK, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 UNIVERSITY DR
Mailing Address - Street 2:FANS
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-2505
Mailing Address - Country:US
Mailing Address - Phone:513-298-3649
Mailing Address - Fax:
Practice Address - Street 1:7700 UNIVERSITY DR
Practice Address - Street 2:FANS
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2505
Practice Address - Country:US
Practice Address - Phone:513-298-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-22
Last Update Date:2017-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD4510133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered