Provider Demographics
NPI:1932689551
Name:CLARK, LATOSSIA BRUNELL
Entity Type:Individual
Prefix:
First Name:LATOSSIA
Middle Name:BRUNELL
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 GEORGE BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:MS
Mailing Address - Zip Code:39743-9425
Mailing Address - Country:US
Mailing Address - Phone:662-352-1375
Mailing Address - Fax:
Practice Address - Street 1:1058 GEORGE BRIDGES RD
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:MS
Practice Address - Zip Code:39743-9425
Practice Address - Country:US
Practice Address - Phone:662-352-1375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1067835133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered