Chanel Clark, RDN, LD
Individual provider Active NPI Registered Dietitian · Indian Valley, ID
NPI 1609424183 · NPPES record last updated Aug 28, 2019
Key facts
- NPI
- 1609424183
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Dietitian 133V00000X
- License
- D-859 (ID)
- Practice address
- 2278 Moritz LN
Indian Valley, ID 83632-5019 - Phone
- (208) 816-8365
- NPI assigned
- Aug 28, 2019
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-859 | ID | MD | Registered Dietitian |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | D-859 | ID | Yes |
Addresses
Primary practice location
2278 Moritz LN
Indian Valley, ID 83632-5019
Mailing address
2278 Moritz LN
Indian Valley, ID 83632-5019
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 28, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.