Provider Demographics
NPI:1770249658
Name:CLARK, EMILY FAITH (RD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:FAITH
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:FAITH
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603
Mailing Address - Country:US
Mailing Address - Phone:254-537-3292
Mailing Address - Fax:
Practice Address - Street 1:111050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:254-537-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered