Provider Demographics
NPI:1609424183
Name:CLARK, CHANEL (RDN, LD)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2278 MORITZ LN
Mailing Address - Street 2:
Mailing Address - City:INDIAN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83632-5019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2278 MORITZ LN
Practice Address - Street 2:
Practice Address - City:INDIAN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83632-5019
Practice Address - Country:US
Practice Address - Phone:208-816-8365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered