Provider Demographics
NPI:1588617195
Name:MCCLENDON, MARY E (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 CAVALIER DR.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4717 CAVALIER DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2933
Practice Address - Country:US
Practice Address - Phone:502-448-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13647Medicaid
NDHP57109OtherHELATHPARTNERS #
ND26200Medicaid
NDDA9011046497OtherPREFERRED ONE #
ND016H5MCOtherMNBS #
ND2003086OtherMEDICA #
ND2394104OtherAMERICA'S PPO/ARAZ #
ND47900OtherLHS #