Basic Information
| Provider Information | |||||||||
| NPI: | 1790940633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCLEMORE | ||||||||
| FirstName: | PHYLLIS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063545585 | ||||||||
| FaxNumber: | 8063564673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 MEDI PARK | ||||||||
| Address2: | STE 2051 | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791062169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064684600 | ||||||||
| FaxNumber: | 8064684398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 03/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 517550 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SP0200X | 517550 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 042483005 | 05 | TX | MEDICAID | 200322680 A | 05 | OK | MEDICAID | 042483006 | 05 | TX | MEDICAID | 05572568 | 05 | NM | MEDICAID |