Provider Demographics
NPI:1871953638
Name:CLARK, CRISTINA ANN (RDN, ATC, C-PT)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDN, ATC, C-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 WRIGHTS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-9115
Mailing Address - Country:US
Mailing Address - Phone:207-717-9224
Mailing Address - Fax:
Practice Address - Street 1:925 UNION ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3051
Practice Address - Country:US
Practice Address - Phone:207-717-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86303770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered