=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962452920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILMA J MC CLAIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 09/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3799 AFSHARI CIR
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63034-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-879-6300
-----------------------------------------------------
Fax | 314-879-6372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5535 DELMAR BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63112-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-879-6300
-----------------------------------------------------
Fax | 314-879-6372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 070184
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------