MEDICARE: LAURA CLARK

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	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1316657166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CLARK

Provider Business Mailing Address
First Line	:	32 ALLEN CT
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2703
Country	:	US
Telephone Number	:	718-640-7774
Fax Number	:

Provider Business Practice Location Address
First Line	:	1498 CLOVE RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4314
Country	:	US
Telephone Number	:	718-494-2690
Fax Number	:

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

Provider Enumeration Date	:	12/02/2022
Last Update Date	:	12/02/2022

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Directions to “ LAURA CLARK ” Practice Location

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