Provider Demographics
NPI:1639804594
Name:MCLAIN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 371795
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-1795
Mailing Address - Country:US
Mailing Address - Phone:470-992-3658
Mailing Address - Fax:470-264-7038
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2212
Practice Address - Country:US
Practice Address - Phone:470-992-3658
Practice Address - Fax:470-264-7038
Is Sole Proprietor?:No
Enumeration Date:2022-07-23
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035931207Q00000X
GARN035931363L00000X
GALPN035931363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609536549OtherNPPES