1508124116 NPI number — MRS. DEMETRIUS MCCLINTON WASHINGTON FNP

Table of content: MRS. DEMETRIUS MCCLINTON WASHINGTON FNP (NPI 1508124116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508124116 NPI number — MRS. DEMETRIUS MCCLINTON WASHINGTON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASHINGTON
Provider First Name:
DEMETRIUS
Provider Middle Name:
MCCLINTON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

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:
1508124116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3440 HOLLYWOOD BLVD
Provider Second Line Business Mailing Address:
SUITE 460
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-6927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-271-9843
Provider Business Mailing Address Fax Number:
186-698-6226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 S SUMMER BREEZE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92808-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-271-9843
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  21078 , 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)





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