Provider Demographics
NPI:1497994966
Name:CLARKE, HANNAH GRACE (RD, LDN, PA-C)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:GRACE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RD, LDN, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1522
Mailing Address - Country:US
Mailing Address - Phone:336-768-3361
Mailing Address - Fax:336-768-4131
Practice Address - Street 1:110 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-768-3361
Practice Address - Fax:336-768-4131
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003231PL133V00000X
NC0010-05131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered