Provider Demographics
NPI:1417605841
Name:CLINKINGBEARD, EMMA GRACE JANEWAY (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:EMMA GRACE
Middle Name:JANEWAY
Last Name:CLINKINGBEARD
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:CLINKINGBEARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:6510 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3427
Mailing Address - Country:US
Mailing Address - Phone:719-440-8794
Mailing Address - Fax:
Practice Address - Street 1:222 S MERAMEC AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3514
Practice Address - Country:US
Practice Address - Phone:719-440-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2700133V00000X
MO2019028506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered