Provider Demographics
NPI:1386031813
Name:MCCLINTON, PRINCE STENA (NP)
Entity type:Individual
Prefix:MRS
First Name:PRINCE
Middle Name:STENA
Last Name:MCCLINTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:PRINCE
Other - Middle Name:STENA
Other - Last Name:MCCLINTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-5578
Mailing Address - Fax:601-984-4151
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-5578
Practice Address - Fax:601-984-4151
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02183861Medicaid
MS463639YJ5DMedicare PIN