Healthcare Provider Details

I. General information

NPI: 1689506461
Provider Name (Legal Business Name): LADONNA G CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CHARLOIS BLVD
WINSTON SALEM NC
27103-1549
US

IV. Provider business mailing address

3777 WINBORNE LN
GREENSBORO NC
27410-2040
US

V. Phone/Fax

Practice location:
  • Phone: 704-440-3580
  • Fax:
Mailing address:
  • Phone: 336-316-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: