Healthcare Provider Details

I. General information

NPI: 1003915414
Provider Name (Legal Business Name): SANDRA SINGLETON CLARK REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 PARAGON PKWY
CLYDE NC
28721-9463
US

IV. Provider business mailing address

181 JOHNS CREEK RD
CANTON NC
28716-5583
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-6675
  • Fax:
Mailing address:
  • Phone: 828-235-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number053719
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: