Provider Demographics
NPI:1720273394
Name:MCCLURE, TINA MARIA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIA
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E 5TH ST
Mailing Address - Street 2:P.O. BOX 504
Mailing Address - City:LAKE PARK
Mailing Address - State:IA
Mailing Address - Zip Code:51347-7745
Mailing Address - Country:US
Mailing Address - Phone:712-832-3888
Mailing Address - Fax:
Practice Address - Street 1:206 E 5TH ST
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:IA
Practice Address - Zip Code:51347-7745
Practice Address - Country:US
Practice Address - Phone:712-832-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0191551OtherMEDICAID PROVIDER NUMBER