Susan B Clark, MS, RD, LD, CDE
Individual provider Active NPI Registered Dietitian · Rexburg, ID
NPI 1124676663 · NPPES record last updated Nov 24, 2025
Key facts
- NPI
- 1124676663
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Dietitian 133V00000X
- License
- D-393 (ID)
- Practice address
- 393 E 2ND N
Rexburg, ID 83440-1605 - Phone
- (208) 356-5401
- NPI assigned
- Aug 28, 2019
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20200318001657 | ID | Practitioner - Registered Dietitian Or Nutrition Professional | 3476980053 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-393 | ID | MD | Registered Dietitian |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Madison Co Memorial Hospital | Current |
Accepting new patients | |
| Madison Co Memorial Hospital | Current | Accepting new patients | |
| Madison Co Memorial Hospital | Current |
Accepting new patients |
Locations
450 E Main St
Rexburg, ID 83440
Phone (208) 356-3691
37 S 2nd E
Rexburg, ID 83440
Phone (208) 356-0234
393 E 2nd N
Rexburg, ID 83440
Phone (208) 356-5401
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | D-393 | ID | Yes |
Addresses
Primary practice location
393 E 2ND N
Rexburg, ID 83440-1605
Mailing address
450 E Main St
Rexburg, ID 83440-2048
Phone (208) 359-6522
Other practice location 1
450 E Main St
Rexburg, ID 83440-2048
Phone (208) 359-6522
Other providers in Rexburg, ID
- Louie Cibrian
- Graciela Maria Clark
- Jack O. Clark
- Kimberly Clark
- Kohlee Clark
- Janell Clement
- Zackery J Cleverley
- Jeffery Michael Clift
- Klarissa Ann Clinger
- Melissa Clinger
All providers in Rexburg, ID · Registered Dietitian in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 24, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.