Provider Demographics
NPI:1720154701
Name:CLARK, HEIDI LYNN (RD)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MDG/MDTS
Mailing Address - Street 2:101 BODIN CIRCLE
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-3665
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/MDTS
Practice Address - Street 2:101 BODIN CIRCLE
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered