Individual
MYMIE T CLINTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
118 ALICE COLEMAN DR, VIDALIA, GA 30474-8860
(912) 537-6565
(912) 537-6161
Mailing address
215 N COLEMAN ST, SWAINSBORO, GA 30401-3530
(912) 537-6565
(912) 537-6161
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
RN040042
GA
363L00000X
Nurse Practitioner
Primary
RN040042
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000632376L
FQHC MEDICAID
GA
05
—
339898116D
—
GA
Enumeration date
07/05/2006
Last updated
01/30/2012
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