Provider Demographics
NPI:1538483748
Name:MCCLURE, DOROTHY LYNNE (CRNA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:LYNNE
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:LYNNE
Other - Last Name:AVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5444 SE QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:KS
Mailing Address - Zip Code:66770
Mailing Address - Country:US
Mailing Address - Phone:636-359-8686
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-1078
Practice Address - Fax:417-347-1079
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010008320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360231Medicare PIN