Provider Demographics
NPI:1720312820
Name:CLARK, NICOLE MARIE (MS RD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SORCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RD
Mailing Address - Street 1:2 CRESCENT PARK WEST
Mailing Address - Street 2:NUTRITION SERVICES
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365
Mailing Address - Country:US
Mailing Address - Phone:814-723-4973
Mailing Address - Fax:
Practice Address - Street 1:2 CRESCENT PARK WEST
Practice Address - Street 2:NUTRITION SERVICES
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365
Practice Address - Country:US
Practice Address - Phone:814-723-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X
NY1004345133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager