Provider Demographics
NPI:1538138250
Name:MCCLELLAN, SHANDRA (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHANDRA
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-6010
Mailing Address - Country:US
Mailing Address - Phone:662-390-8992
Mailing Address - Fax:662-335-7933
Practice Address - Street 1:2119 HIGHWAY 82 EAST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703
Practice Address - Country:US
Practice Address - Phone:662-390-8992
Practice Address - Fax:662-335-7933
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS124379Medicaid
MS500000823Medicare ID - Type Unspecified