NPI 1124676663 · live from the CMS NPI Registry
Susan B Clark, MS, RD, LD, CDE
Dietitian, Registered in Rexburg, ID. National Provider Identifier 1124676663, active.
NPI record
| NPI | 1124676663 Type 1 · individual |
|---|---|
| Status | Active |
| Primary specialty | Dietitian, Registered 133V00000X |
| Practice location | 393 E 2nd N, Rexburg, ID 83440 |
| Practice phone | 208-356-5401 |
| Mailing address | 450 E Main St, Rexburg, ID 83440 |
| Enumerated | August 28, 2019 |
| Last updated | November 24, 2025 |
| Sole proprietor | No |
Taxonomies and licenses
| Taxonomy | Code | License |
|---|---|---|
| Dietitian, Registered primary | 133V00000X | D-393 (ID) |
Source: CMS NPPES NPI Registry. NPI data is self-reported by providers; license numbers are not verified by CMS.