Provider Demographics
NPI:1053352187
Name:CLARK, KRISTA CARRIE (RD LMNT)
Entity type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:CARRIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RD LMNT
Other - Prefix:MS
Other - First Name:KRISTA
Other - Middle Name:CARRIE
Other - Last Name:SKAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LMNT
Mailing Address - Street 1:450 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2303
Mailing Address - Country:US
Mailing Address - Phone:402-727-3726
Mailing Address - Fax:402-727-3433
Practice Address - Street 1:450 E 23RD ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2303
Practice Address - Country:US
Practice Address - Phone:402-727-3726
Practice Address - Fax:402-727-3433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE633133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE278298Medicare ID - Type Unspecified