MEDICARE: WILMA J MC CLAIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	070184	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1962452920	OTHER	MO	NATIONAL PROVIDER IDENTIFIER
4	11638556	OTHER	MO	CAQH

General Provider Information

NPI Number	:	1962452920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILMA J MC CLAIN

Provider Business Mailing Address
First Line	:	5535 DELMAR BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-3005
Country	:	US
Telephone Number	:	314-879-6300
Fax Number	:	314-879-6372

Provider Business Practice Location Address
First Line	:	3799 AFSHARI CIR
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63034-1527
Country	:	US
Telephone Number	:	314-879-6300
Fax Number	:	314-879-6372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	09/19/2011

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