Provider Demographics
NPI:1609117514
Name:CLARK, MAE PALINA (RD)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:PALINA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:PALINA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:900 STARK RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3613
Mailing Address - Country:US
Mailing Address - Phone:662-323-4400
Mailing Address - Fax:662-323-4409
Practice Address - Street 1:900 STARK RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3613
Practice Address - Country:US
Practice Address - Phone:662-323-4400
Practice Address - Fax:662-323-4409
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1275133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered