Provider Demographics
NPI:1487129649
Name:RUNNELS, CLARENCE DAVID III (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:DAVID
Last Name:RUNNELS
Suffix:III
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 KEISLER DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7099
Mailing Address - Country:US
Mailing Address - Phone:919-601-6442
Mailing Address - Fax:
Practice Address - Street 1:523 KEISLER DR STE 202
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7099
Practice Address - Country:US
Practice Address - Phone:919-601-6442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011070363LP0808X, 2084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2018010871OtherANCC CERTIFICATION NUMBER
NC5011070OtherNCBON LICENSE NUMBER