Provider Demographics
NPI:1376550137
Name:CLANTON, THERESA LEE
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LEE
Last Name:CLANTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:LEE
Other - Last Name:CLANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:696 CARTER ROUTE M
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:MO
Mailing Address - Zip Code:63965-7014
Mailing Address - Country:US
Mailing Address - Phone:573-323-2171
Mailing Address - Fax:
Practice Address - Street 1:402 MAIN ST.
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:MO
Practice Address - Zip Code:63965
Practice Address - Country:US
Practice Address - Phone:573-323-4853
Practice Address - Fax:573-323-4465
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
MO475-1246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376K00000XNursing Service Related ProvidersNurse's Aide