Provider Demographics
NPI:1689635724
Name:MARILYN J. MCCLURE
Entity Type:Organization
Organization Name:MARILYN J. MCCLURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN-FNP
Authorized Official - Phone:707-986-7176
Mailing Address - Street 1:448 SEAFOAM RD
Mailing Address - Street 2:
Mailing Address - City:SHELTER COVE
Mailing Address - State:CA
Mailing Address - Zip Code:95589-9107
Mailing Address - Country:US
Mailing Address - Phone:707-986-7176
Mailing Address - Fax:
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-577-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC148295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP0131510OtherBLUE SHIELD INSURANCE CO
CAZZZ23466ZMedicare ID - Type Unspecified