Provider Demographics
NPI:1801298278
Name:MCLIN, PHAEDRA (NP)
Entity type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:
Last Name:MCLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PHAEDRA
Other - Middle Name:
Other - Last Name:PATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 HIGHWAY 589
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-4194
Mailing Address - Country:US
Mailing Address - Phone:601-794-0100
Mailing Address - Fax:
Practice Address - Street 1:823 HIGHWAY 589
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4194
Practice Address - Country:US
Practice Address - Phone:601-794-0100
Practice Address - Fax:601-794-0247
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856419363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06676328Medicaid
MS06676328Medicaid