Provider Demographics
NPI:1497339345
Name:MCCLELLAN, KELLY JO (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14969 S EAGLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-2458
Mailing Address - Country:US
Mailing Address - Phone:814-414-8589
Mailing Address - Fax:
Practice Address - Street 1:3438 ROUTE 764
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-7803
Practice Address - Country:US
Practice Address - Phone:814-944-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN289417164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse