Provider Demographics
NPI:1578618336
Name:CLARK, AMY (RD, LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:3801 S JAMES ST STE 400
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-5167
Mailing Address - Country:US
Mailing Address - Phone:515-695-3768
Mailing Address - Fax:833-719-1241
Practice Address - Street 1:3801 S JAMES ST STE 400
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-5167
Practice Address - Country:US
Practice Address - Phone:515-695-3768
Practice Address - Fax:833-719-1241
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01650133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15114Medicare PIN
IAQ42786Medicare UPIN