Provider Demographics
NPI:1881625598
Name:CLINTON, MYMIE T (NP)
Entity type:Individual
Prefix:
First Name:MYMIE
Middle Name:T
Last Name:CLINTON
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 1:215 N COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3530
Mailing Address - Country:US
Mailing Address - Phone:912-537-6565
Mailing Address - Fax:912-537-6161
Practice Address - Street 1:118 ALICE COLEMAN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8860
Practice Address - Country:US
Practice Address - Phone:912-537-6565
Practice Address - Fax:912-537-6161
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN040042163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000632376LOtherFQHC MEDICAID
GA339898116DMedicaid
GA339898116DMedicaid
GAQ59822Medicare UPIN