Provider Demographics
NPI:1275503633
Name:MCCLANAHAN, KATHLEEN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:MCCLANAHAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24035 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-4871
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:24035 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-4871
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:301-373-6900
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN63775363L00000X
MDR128846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036204800Medicaid
DC406281700Medicaid
MD406281701Medicaid
DCQ18070Medicare UPIN
DC014429W17Medicare ID - Type UnspecifiedTRAILBLAZER
DCP00194595Medicare ID - Type UnspecifiedRAILROAD