Provider Demographics
NPI:1730454240
Name:MACKLIN, STEPHANIE SUZANNE (FNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:SHELLEY
Other - Last Name:MACKLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1101 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-3701
Mailing Address - Country:US
Mailing Address - Phone:806-655-7155
Mailing Address - Fax:806-655-7145
Practice Address - Street 1:1101 4TH AVE
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-3701
Practice Address - Country:US
Practice Address - Phone:806-655-7155
Practice Address - Fax:806-655-7145
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX769409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX873N94OtherBCBS TEXAS
TX368518ZGKVMedicare UPIN