Healthcare Provider Details

I. General information

NPI: 1689635724
Provider Name (Legal Business Name): MARILYN J. MCCLURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MENDOCINO AVE SUITE 360
SANTA ROSA CA
95403-3634
US

IV. Provider business mailing address

448 SEAFOAM RD
SHELTER COVE CA
95589-9107
US

V. Phone/Fax

Practice location:
  • Phone: 707-577-7800
  • Fax:
Mailing address:
  • Phone: 707-986-7176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC148295
License Number StateCA

VIII. Authorized Official

Name: MRS. MARILYN JEANNE MCCLURE
Title or Position: FAMILY NURSE PRACTITIONER
Credential: MSN-FNP
Phone: 707-986-7176