Provider Demographics
NPI:1447393491
Name:MCLELLAN, CAROL Y
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:Y
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BIANCA RD
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 ADMINISTRATION RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-3230
Practice Address - Country:US
Practice Address - Phone:508-279-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA.94009363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner