Healthcare Provider Details

I. General information

NPI: 1093944654
Provider Name (Legal Business Name): KRISTINE NOEL CLARK RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2009
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 DEWAR DR # 204
ROCK SPRINGS WY
82901-5814
US

IV. Provider business mailing address

1010 ARROWHEAD CIR
ROCK SPRINGS WY
82901-7288
US

V. Phone/Fax

Practice location:
  • Phone: 919-564-9064
  • Fax: 307-316-0228
Mailing address:
  • Phone: 919-564-9064
  • Fax: 307-316-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number117
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number117
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: