Provider Demographics
NPI:1962452920
Name:MC CLAIN, WILMA J
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:J
Last Name:MC CLAIN
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 1:5535 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3005
Mailing Address - Country:US
Mailing Address - Phone:314-879-6300
Mailing Address - Fax:314-879-6372
Practice Address - Street 1:3799 AFSHARI CIR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-1527
Practice Address - Country:US
Practice Address - Phone:314-879-6300
Practice Address - Fax:314-879-6372
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO070184363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427400601Medicaid
MO815392931Medicaid
MO1962452920OtherNATIONAL PROVIDER IDENTIFIER
MO11638556OtherCAQH
MO11638556OtherCAQH