Provider Demographics
NPI:1992745954
Name:CLARK, KATHRYN M (MPH, RD)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPH, RD
Mailing Address - Street 1:221 ISLAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6936
Mailing Address - Country:US
Mailing Address - Phone:619-255-8855
Mailing Address - Fax:858-876-1944
Practice Address - Street 1:221 ISLAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6936
Practice Address - Country:US
Practice Address - Phone:619-255-8855
Practice Address - Fax:858-876-1944
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03163ZMedicare UPIN