Provider Demographics
NPI:1114582566
Name:MCCLENDON, TIFFANY LINN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LINN
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 FM 2419
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-5560
Mailing Address - Country:US
Mailing Address - Phone:903-948-6405
Mailing Address - Fax:
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143317363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner