Healthcare Provider Details

I. General information

NPI: 1992994578
Provider Name (Legal Business Name): LISA DIANNE MCCLURE LPN 880563
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RAINBOW DR UNIT 35
PINEVILLE LA
71360-6979
US

IV. Provider business mailing address

401 RAINBOW DR UNIT 35
PINEVILLE LA
71360-6979
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5191
  • Fax: 318-487-5453
Mailing address:
  • Phone: 318-487-5191
  • Fax: 318-487-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN 880563
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: