Provider Demographics
NPI:1952675209
Name:CLARK, SHERRY L (NP)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3669
Mailing Address - Country:US
Mailing Address - Phone:336-621-8911
Mailing Address - Fax:336-621-6322
Practice Address - Street 1:2703 HENRY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3669
Practice Address - Country:US
Practice Address - Phone:336-621-8911
Practice Address - Fax:336-621-6322
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169814363L00000X
NC5006703363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCH402AMedicare PIN
NC185HXOtherBCBS