Provider Demographics
NPI:1356694301
Name:CLARK, WILLIAM ANDREW (PHD, RD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ANDREW
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 UNIVERSITY PKWY
Mailing Address - Street 2:BOX 70403
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-6500
Mailing Address - Country:US
Mailing Address - Phone:423-439-4071
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:807 UNIVERSITY PKWY
Practice Address - Street 2:BOX 70403
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-6500
Practice Address - Country:US
Practice Address - Phone:423-439-4071
Practice Address - Fax:423-439-4060
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN2487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLDN0000002487OtherST LIC