Provider Demographics
NPI:1467752436
Name:CLARK, LESLIE MASON (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:MASON
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1054
Mailing Address - Country:US
Mailing Address - Phone:270-686-7747
Mailing Address - Fax:
Practice Address - Street 1:472 KLUTEY PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3348
Practice Address - Country:US
Practice Address - Phone:270-826-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered