Provider Demographics
NPI:1053032243
Name:CLARK, LAUREN (MS, RD, LD, CNSC)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RD, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E HOUSTON ST STE 270
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 320
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8369
Practice Address - Country:US
Practice Address - Phone:903-606-4300
Practice Address - Fax:903-606-1283
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1301X
TXDT81072133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology