Healthcare Provider Details

I. General information

NPI: 1316657166
Provider Name (Legal Business Name): LAURA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 CLOVE RD
STATEN ISLAND NY
10301-4314
US

IV. Provider business mailing address

32 ALLEN CT
STATEN ISLAND NY
10310-2703
US

V. Phone/Fax

Practice location:
  • Phone: 718-494-2690
  • Fax:
Mailing address:
  • Phone: 718-640-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: