Provider Demographics
NPI:1649676842
Name:CLARK, XONNA (MS, CNS, LDN)
Entity type:Individual
Prefix:MS
First Name:XONNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 ERFURT CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2870
Mailing Address - Country:US
Mailing Address - Phone:704-516-6973
Mailing Address - Fax:
Practice Address - Street 1:9115 ERFURT CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2870
Practice Address - Country:US
Practice Address - Phone:704-516-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-15
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3670133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist