Provider Demographics
NPI:1588987200
Name:MCCLENNY, LAURA SUE (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SUE
Last Name:MCCLENNY
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:3802 MANHATTON DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9451
Practice Address - Country:US
Practice Address - Phone:903-509-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX669980363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00820916OtherRAIL ROAD MEDICARE
TX75-2616977-118OtherTRICARE
TXTIN PLUS 020OtherTRICARE
TX211234401Medicaid
TX817N75OtherBCBS
TXTIN PLUS 020OtherTRICARE