Provider Demographics
NPI:1598761389
Name:MCCLELLAN, NANCY (GNP)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 S OAKWOOD TER
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-6832
Mailing Address - Country:US
Mailing Address - Phone:414-529-9518
Mailing Address - Fax:
Practice Address - Street 1:5700 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4016
Practice Address - Country:US
Practice Address - Phone:414-531-9518
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI91660-030363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43864200Medicaid