Provider Demographics
NPI:1386854560
Name:MCLELLAN, CONNIE L (RD, LD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1428
Mailing Address - Country:US
Mailing Address - Phone:207-834-1569
Mailing Address - Fax:207-834-4048
Practice Address - Street 1:3 MOUNTAINVIEW DR.
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1409
Practice Address - Country:US
Practice Address - Phone:207-834-1569
Practice Address - Fax:207-834-4048
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI96133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMC MT0008Medicare ID - Type Unspecified