Provider Demographics
NPI:1093721359
Name:CLARK, SUSAN KAY (MS, RD, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RD, IBCLC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, IBCLC
Mailing Address - Street 1:2621 W WACKERLY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6993
Mailing Address - Country:US
Mailing Address - Phone:989-832-8322
Mailing Address - Fax:
Practice Address - Street 1:2621 W WACKERLY ST
Practice Address - Street 2:SUITE D
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6993
Practice Address - Country:US
Practice Address - Phone:989-832-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered