Basic Information
| Provider Information | |||||||||
| NPI: | 1902042229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637775 | ||||||||
| FaxNumber: | 4794637187 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 EAST APPLEBY RD. | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794041140 | ||||||||
| FaxNumber: | 4794041141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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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 | 326 | AR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.