Provider Demographics
NPI:1164910923
Name:CLARK, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
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 1:8100 RAVINES EDGE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8100 RAVINES EDGE COURT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235
Practice Address - Country:US
Practice Address - Phone:614-985-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171M00000X
OHLD.6860133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator