Provider Demographics
NPI:1467499244
Name:DECLUE, PATRICIA (FNP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:DECLUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3431
Mailing Address - Country:US
Mailing Address - Phone:307-332-2941
Mailing Address - Fax:307-332-1920
Practice Address - Street 1:1460 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2657
Practice Address - Country:US
Practice Address - Phone:307-332-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8949.317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120173500Medicaid
WY20627Medicare ID - Type Unspecified
WYQ29641Medicare UPIN