Healthcare Provider Details

I. General information

NPI: 1770419772
Provider Name (Legal Business Name): EDITH CLOGG RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 ASH ST APT 507
DENVER CO
80220-3743
US

IV. Provider business mailing address

1155 ASH ST APT 507
DENVER CO
80220-3743
US

V. Phone/Fax

Practice location:
  • Phone: 814-360-2683
  • Fax:
Mailing address:
  • Phone: 814-360-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1000127
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: