Provider Demographics
NPI:1376040493
Name:CLARK, LORI RENEE (RD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 THISTLE FINCH
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7768
Mailing Address - Country:US
Mailing Address - Phone:317-965-0892
Mailing Address - Fax:
Practice Address - Street 1:1201 HADLEY RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1737
Practice Address - Country:US
Practice Address - Phone:317-528-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN879437133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered