Basic Information
| Provider Information | |||||||||
| NPI: | 1053352187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | CARRIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD LMNT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SKAHAN | ||||||||
| OtherFirstName: | KRISTA | ||||||||
| OtherMiddleName: | CARRIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD LMNT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 450 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027273726 | ||||||||
| FaxNumber: | 4027273433 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027273726 | ||||||||
| FaxNumber: | 4027273433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 633 | NE | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.