Provider Demographics
NPI:1558672584
Name:CLARK, HEATHER MARIE NETTLES (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MARIE NETTLES
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7045 ORCHARD PATH DR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8222
Mailing Address - Country:US
Mailing Address - Phone:336-655-7271
Mailing Address - Fax:
Practice Address - Street 1:190 KIMEL PARK DRIVE
Practice Address - Street 2:VETERANS AFFAIRS WINSTON SALEM OUTPATIENT CLINIC
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-004762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry