Provider Demographics
NPI:1497736995
Name:MCLEMORE, CHARLES G (FNP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:G
Last Name:MCLEMORE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5252
Mailing Address - Country:US
Mailing Address - Phone:337-497-9355
Mailing Address - Fax:337-437-3692
Practice Address - Street 1:1106 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5252
Practice Address - Country:US
Practice Address - Phone:337-497-9355
Practice Address - Fax:337-437-3692
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN078593-AP03159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1531812Medicaid
LA1531812Medicaid
LA5X307Medicare ID - Type Unspecified