Provider Demographics
NPI:1881203636
Name:KING, CLAIRE MALLOY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:MALLOY
Last Name:KING
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 1:2408 TEMPLE CT W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-6825
Mailing Address - Country:US
Mailing Address - Phone:765-722-0067
Mailing Address - Fax:
Practice Address - Street 1:412 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9702
Practice Address - Country:US
Practice Address - Phone:260-358-7180
Practice Address - Fax:260-755-5731
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86173803OtherCOMMISSION ON DIETETIC REGISTRATION