Basic Information
| Provider Information | |||||||||
| NPI: | 1396036570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENS | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | DEYOUNG | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POPPE | ||||||||
| OtherFirstName: | CLAIRE | ||||||||
| OtherMiddleName: | DEYOUNG | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | MC 2433 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537921530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086620817 | ||||||||
| FaxNumber: | 6082034544 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | MC 2433 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537921530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086620817 | ||||||||
| FaxNumber: | 6082034544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 01020890-RD | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 01020890-RD | 01 | WI | REGISTERED DIETITIAN | OTHER |