Basic Information
| Provider Information | |||||||||
| NPI: | 1548444219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | SHERYLL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LD RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899667 | ||||||||
| Practice Location | |||||||||
| Address1: | 3311 E MURDOCK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899251 | ||||||||
| FaxNumber: | 3166899769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 365 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 003719001 | 01 | MEDICARE | OTHER | 200539620A | 05 | KS | MEDICAID |