Healthcare Provider Details

I. General information

NPI: 1790935427
Provider Name (Legal Business Name): CONNIE MCCLARAN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 HEWITT ST
MCCALL ID
83638
US

IV. Provider business mailing address

1000 STATE ST
MCCALL ID
83638-3704
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-1400
  • Fax: 208-634-4044
Mailing address:
  • Phone: 208-634-1400
  • Fax: 208-634-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN-16879
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: