Provider Demographics
NPI:1427488048
Name:CLARK, LANA KALLEEN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:LANA
Middle Name:KALLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MISS
Other - First Name:LANA
Other - Middle Name:KALLEEN
Other - Last Name:HOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:2965 MANSON ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1029
Mailing Address - Country:US
Mailing Address - Phone:612-289-0644
Mailing Address - Fax:
Practice Address - Street 1:2800 CLEVELAND AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1126
Practice Address - Country:US
Practice Address - Phone:651-642-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered