Provider Demographics
NPI:1447401500
Name:MCCLELLAND, NICOLE LEE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:MCCLELLAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 GOLF VIEW DR
Mailing Address - Street 2:SUITE # 200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9685
Mailing Address - Country:US
Mailing Address - Phone:541-618-4400
Mailing Address - Fax:541-618-4406
Practice Address - Street 1:760 GOLF VIEW DR
Practice Address - Street 2:SUITE # 200
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9685
Practice Address - Country:US
Practice Address - Phone:541-618-4400
Practice Address - Fax:541-618-4406
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1824363L00000X
OR201050102NP363L00000X
NE110995363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201041420RNOtherSTATE LICENSE - RN
NE52664OtherRN STATE LICENSE
OR201050102NPOtherSTATE - ANP
OR500629049Medicaid
NE110995OtherAPRN STATE LICENSE