Provider Demographics
NPI:1093944654
Name:CLARK, KRISTINE NOEL (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:NOEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 ARROWHEAD CIR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-7288
Mailing Address - Country:US
Mailing Address - Phone:919-564-9064
Mailing Address - Fax:307-316-0228
Practice Address - Street 1:1471 DEWAR DR # 204
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5814
Practice Address - Country:US
Practice Address - Phone:919-564-9064
Practice Address - Fax:307-316-0228
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-03
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY117133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic