Provider Demographics
NPI:1295462661
Name:CLARKE, KRISTA (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MACMILLAN AVE N
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 MACMILLAN AVE N
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5248
Practice Address - Country:US
Practice Address - Phone:267-229-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered