Individual
MRS. THERESA S. CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSRD,C.D.E., L.D.
Contact information
Practice address
530 NOEL AVE, HOPKINSVILLE, KY 42240-1386
(270) 707-0060
(270) 707-0068
Mailing address
530 NOEL AVE, HOPKINSVILLE, KY 42240-1386
(270) 707-0060
(270) 707-0068
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
KY-0517
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
38364492
TAX ID NO.
KY
05
—
9000505900
—
KY
01
—
KY-0517
LICENSE DIETITIAN
KY
Enumeration date
05/07/2007
Last updated
08/05/2016
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