Basic Information
| Provider Information | |||||||||
| NPI: | 1205249182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLEAN | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.S.N. RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCLEAN | ||||||||
| OtherFirstName: | MARCIA | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S.N. RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1132 N CYPRESS AVE | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740128562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182541833 | ||||||||
| FaxNumber: | 9182547155 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741204429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185879471 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | R0068362 | OK | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.