Provider Demographics
NPI:1356144489
Name:CLARK, INGRID (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 N ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5073
Mailing Address - Country:US
Mailing Address - Phone:608-438-1612
Mailing Address - Fax:
Practice Address - Street 1:740 N OGDEN AVE APT 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7063
Practice Address - Country:US
Practice Address - Phone:608-438-1612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006684133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered