Provider Demographics
NPI:1477603694
Name:MCCLAMROCH, YVONNE SUZETTE (FNP)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:SUZETTE
Last Name:MCCLAMROCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-906-4623
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:3544 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-4120
Practice Address - Country:US
Practice Address - Phone:619-515-2424
Practice Address - Fax:619-906-4564
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451416363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN451416Medicaid
Q17204Medicare UPIN
CARN451416Medicaid