1689635724 NPI number — MARILYN J. MCCLURE

Table of content: (NPI 1689635724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689635724 NPI number — MARILYN J. MCCLURE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARILYN J. MCCLURE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689635724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
448 SEAFOAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTER COVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95589-9107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-986-7176
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3536 MENDOCINO AVE
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-577-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLURE
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
JEANNE
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
707-986-7176

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  C148295 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP0131510 . This is a "BLUE SHIELD INSURANCE CO" identifier . This identifiers is of the category "OTHER".




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