Provider Demographics
NPI:1629180815
Name:MCCLELLAN, CHARLOTTE A
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:A
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 ASHRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4136
Mailing Address - Country:US
Mailing Address - Phone:601-898-1472
Mailing Address - Fax:
Practice Address - Street 1:404 ASHRIDGE PL
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4136
Practice Address - Country:US
Practice Address - Phone:601-898-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR784906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered