Provider Demographics
NPI:1790940633
Name:MCLEMORE, PHYLLIS (NP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MCLEMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:1901 MEDI PARK
Practice Address - Street 2:STE 2051
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2169
Practice Address - Country:US
Practice Address - Phone:806-468-4600
Practice Address - Fax:806-468-4398
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX517550363L00000X, 364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX042483005Medicaid
OK200322680 AMedicaid
TX042483006Medicaid
NM05572568Medicaid
TX042483005Medicaid