Provider Demographics
NPI:1740981893
Name:CLARK, TAYLOR NICOLE (RD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:NICOLE
Other - Last Name:ASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 49702
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0702
Mailing Address - Country:US
Mailing Address - Phone:219-488-6226
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered