Provider Demographics
NPI:1578891040
Name:CLARK, CHELSEA C (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EAST RD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-4450
Mailing Address - Country:US
Mailing Address - Phone:802-363-3297
Mailing Address - Fax:
Practice Address - Street 1:15 EAST RD UNIT 102
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VT
Practice Address - Zip Code:05454-4450
Practice Address - Country:US
Practice Address - Phone:802-363-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-22
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0086622163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant