Provider Demographics
NPI:1679611057
Name:MCCLURE, MARILYN P (FNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:P
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:481 ROUTE 11
Practice Address - Street 2:
Practice Address - City:CHAMPLAIN
Practice Address - State:NY
Practice Address - Zip Code:12919-4819
Practice Address - Country:US
Practice Address - Phone:518-298-2691
Practice Address - Fax:518-298-8241
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333049363LF0000X
NYF333049-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02280546Medicaid
NYP35782Medicare UPIN
NYJ400079269Medicare PIN