Basic Information
Provider Information | |||||||||
NPI: | 1265423347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCLEAN | ||||||||
FirstName: | JOAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 104 E 16TH ST | ||||||||
Address2: |   | ||||||||
City: | HOPE | ||||||||
State: | AR | ||||||||
PostalCode: | 718017424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707770007 | ||||||||
FaxNumber: | 8707770061 | ||||||||
Practice Location | |||||||||
Address1: | 104 E 16TH ST | ||||||||
Address2: |   | ||||||||
City: | HOPE | ||||||||
State: | AR | ||||||||
PostalCode: | 718017424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707770007 | ||||||||
FaxNumber: | 8707770061 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2005 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | A01251 ANP | AR | Y |   | Nursing Service Providers | Licensed Practical Nurse |   |
ID Information
ID | Type | State | Issuer | Description | P00194875 | 01 | AR | PALAMETTO RETIRED RAILROA | OTHER | 5C874 | 01 | AR | ARKANSAS BCBS | OTHER |