Provider Demographics
NPI:1720664113
Name:CLEMONS, MATTHEW ANTOINNE (NP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTOINNE
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1404 THE PINES PL
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1742
Mailing Address - Country:US
Mailing Address - Phone:919-368-8839
Mailing Address - Fax:984-297-8776
Practice Address - Street 1:833 WAKE FOREST BUSINESS PARK STE F
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7184
Practice Address - Country:US
Practice Address - Phone:919-306-6074
Practice Address - Fax:984-297-8776
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5014248363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health