Basic Information
| Provider Information | |||||||||
| NPI: | 1750956280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ZADADRIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2065 MORGAN CIR APT 302 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271275150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042904524 | ||||||||
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| Practice Location | |||||||||
| Address1: | 418B W MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047804271 | ||||||||
| FaxNumber: | 8882616694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2021 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | NC | Y |
No ID Information.