Provider Demographics
NPI:1609297431
Name:CLARK, CANDACE (RD, CD, CDE)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 DELWARE STREET
Mailing Address - Street 2:P.O. BOX 3002
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-414-2000
Mailing Address - Fax:
Practice Address - Street 1:1615 DELWARE STREET
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-414-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60269049133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered