MEDICARE: KATIE D CLARK RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1689455594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE D CLARK RD, LDN

Provider Business Mailing Address
First Line	:	1807 WATERLOO ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-2422
Country	:	US
Telephone Number	:	267-768-8739
Fax Number	:

Provider Business Practice Location Address
First Line	:	1807 WATERLOO ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-2422
Country	:	US
Telephone Number	:	267-768-8739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	10/09/2023

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