Provider Demographics
NPI:1669492328
Name:MCCLOY, MARY KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:MCCLOY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5655
Mailing Address - Country:US
Mailing Address - Phone:310-825-6301
Mailing Address - Fax:310-794-9718
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#365,420,530,120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-5655
Practice Address - Country:US
Practice Address - Phone:310-825-6301
Practice Address - Fax:310-794-9718
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP8445207RC0000X, 363L00000X, 363LA2100X
CARN369858163W00000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3698580Medicaid
CAWNP8445BMedicare PIN
CAGT709ZMedicare PIN
CARN3698580Medicaid