Provider Demographics
NPI:1104540871
Name:CLARK, RYLEIGH (RD, LD)
Entity type:Individual
Prefix:
First Name:RYLEIGH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E WALNUT LAWN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7865
Mailing Address - Country:US
Mailing Address - Phone:417-269-3900
Mailing Address - Fax:
Practice Address - Street 1:960 E WALNUT LAWN ST STE 203
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7865
Practice Address - Country:US
Practice Address - Phone:417-269-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022033517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered