Provider Demographics
NPI:1518670025
Name:CLARK-HIBBS, GRACE STERLING
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:STERLING
Last Name:CLARK-HIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33295
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3295
Mailing Address - Country:US
Mailing Address - Phone:505-705-8311
Mailing Address - Fax:
Practice Address - Street 1:3242 NE 108TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2742
Practice Address - Country:US
Practice Address - Phone:505-705-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered