Provider Demographics
NPI:1467133546
Name:MCCLELAND, CARLY JO (RN, SRNA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JO
Last Name:MCCLELAND
Suffix:
Gender:F
Credentials:RN, SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1712
Mailing Address - Country:US
Mailing Address - Phone:618-973-5330
Mailing Address - Fax:
Practice Address - Street 1:542 GEORGE ST
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1712
Practice Address - Country:US
Practice Address - Phone:618-973-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041513364163WP0200X
MO2016013693163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine