Provider Demographics
NPI:1548833098
Name:MCCLAIN, MARY GWYNNE (RN, BSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GWYNNE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 S EICKHOFF RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-9006
Mailing Address - Country:US
Mailing Address - Phone:812-985-9878
Mailing Address - Fax:
Practice Address - Street 1:714 S EICKHOFF RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-9006
Practice Address - Country:US
Practice Address - Phone:812-985-9878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28119948A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care