Healthcare Provider Details

I. General information

NPI: 1669492328
Provider Name (Legal Business Name): MARY KATHLEEN MCCLOY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA #365,420,530,120
LOS ANGELES CA
90095-5655
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5655
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6301
  • Fax: 310-794-9718
Mailing address:
  • Phone: 310-825-6301
  • Fax: 310-794-9718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP8445
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP8445
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN369858
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN369858
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberNP8445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: