Provider Demographics
NPI:1265908818
Name:CLARK, KATHERINE SOMERS (MS,RDN,CNSC,LD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SOMERS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS,RDN,CNSC,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2443 S CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-8403
Mailing Address - Country:US
Mailing Address - Phone:417-388-3812
Mailing Address - Fax:
Practice Address - Street 1:2615 E 20TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1039
Practice Address - Country:US
Practice Address - Phone:417-624-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001013727133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2001013727OtherLICENSE