Provider Demographics
NPI:1528399748
Name:MCLELLAN, TARA L (ARNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12440 MAGNOLIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36555-6434
Mailing Address - Country:US
Mailing Address - Phone:251-263-4991
Mailing Address - Fax:888-339-7886
Practice Address - Street 1:12440 MAGNOLIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:MAGNOLIA SPRINGS
Practice Address - State:AL
Practice Address - Zip Code:36555-6434
Practice Address - Country:US
Practice Address - Phone:251-263-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9299613363LF0000X
AL1-124579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063439065OtherNPI SITE GROUP PAYEE NUMBER
AL630000013Medicaid
AL011846OtherMEDICARE GROUP NUMBER