Provider Demographics
NPI:1508376526
Name:CLARKE, CORAL C (RDN)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:C
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 CENTER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2265
Mailing Address - Country:US
Mailing Address - Phone:716-464-2508
Mailing Address - Fax:716-304-2508
Practice Address - Street 1:73 CENTER ST APT 3
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2265
Practice Address - Country:US
Practice Address - Phone:716-464-2508
Practice Address - Fax:716-304-2508
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86065331133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered