Provider Demographics
NPI:1134613953
Name:CLARK, LISA P (RD,LDN, CNSC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD,LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6274
Mailing Address - Country:US
Mailing Address - Phone:773-665-3326
Mailing Address - Fax:773-665-3231
Practice Address - Street 1:2900 N LAKESHORE DRIVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-665-3326
Practice Address - Fax:773-665-3231
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000736133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered