Provider Demographics
NPI:1073892832
Name:CLARK, CARLA BETH (RD, LD, RN)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:BETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, LD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-0636
Mailing Address - Country:US
Mailing Address - Phone:478-240-2181
Mailing Address - Fax:478-240-2020
Practice Address - Street 1:610 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1860
Practice Address - Country:US
Practice Address - Phone:478-240-2181
Practice Address - Fax:478-240-2020
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002458133V00000X
GARN207257163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse