Healthcare Provider Details

I. General information

NPI: 1497994966
Provider Name (Legal Business Name): HANNAH GRACE CLARKE RD, LDN, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3361
  • Fax: 336-768-4131
Mailing address:
  • Phone: 336-768-3361
  • Fax: 336-768-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003231PL
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05131
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: