Provider Demographics
NPI:1760490338
Name:CLARK, CYNTHIA (RD)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 CRESTEDGE LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-2503
Mailing Address - Country:US
Mailing Address - Phone:301-257-3299
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:WASHINGTON CA INSTITUTE - RM. C1213
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-3498
Practice Address - Fax:202-877-8539
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCQ59654Medicare UPIN
DC018616W91Medicare ID - Type UnspecifiedDC MEDICAID