Provider Demographics
NPI:1952580862
Name:MCCLURE, THERESA KAY (NP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:KAY
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3403 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-957-2000
Mailing Address - Fax:317-957-2050
Practice Address - Street 1:811 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2212
Practice Address - Country:US
Practice Address - Phone:812-333-4001
Practice Address - Fax:812-333-4057
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000048A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200185140Medicaid
INM400072438Medicare PIN
NY2E7251Medicare PIN
IN200185140Medicaid
NY2394190Medicaid