Provider Demographics
NPI:1124632682
Name:CLARK, SAMANNTHA (RDN)
Entity type:Individual
Prefix:
First Name:SAMANNTHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18219 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-6360
Mailing Address - Country:US
Mailing Address - Phone:425-299-1031
Mailing Address - Fax:
Practice Address - Street 1:18219 BUTLER RD
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-6360
Practice Address - Country:US
Practice Address - Phone:425-299-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered