Provider Demographics
NPI:1346913274
Name:CLARK, LAKIN
Entity Type:Individual
Prefix:
First Name:LAKIN
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 1:485 N KS HWY 2
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:KS
Mailing Address - Zip Code:67003-2526
Mailing Address - Country:US
Mailing Address - Phone:620-914-1200
Mailing Address - Fax:620-914-1267
Practice Address - Street 1:485 N KS HWY 2
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:KS
Practice Address - Zip Code:67003-2526
Practice Address - Country:US
Practice Address - Phone:620-914-1200
Practice Address - Fax:620-914-1267
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered