Provider Demographics
NPI:1124116116
Name:CLARK, NANCY (MS RD)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650124
Mailing Address - Street 2:60 LINDBERGH AVE
Mailing Address - City:WEST NEWTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02465
Mailing Address - Country:US
Mailing Address - Phone:617-795-1875
Mailing Address - Fax:617-795-1876
Practice Address - Street 1:1300 BOYLSTON ST
Practice Address - Street 2:HEALTH WORKS FITNESS CENTER
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467
Practice Address - Country:US
Practice Address - Phone:617-383-6100
Practice Address - Fax:617-795-1876
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA#736133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA402096OtherTUFTS HEALTH PLAN
CLMT0517Medicare ID - Type Unspecified