Provider Demographics
NPI:1629584461
Name:MCCLELLAN, BENJAMIN WAYNE (NP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WAYNE
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 EAST THIRD STREET
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-9001
Mailing Address - Fax:423-778-4692
Practice Address - Street 1:979 E 3RD ST STE C830
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-3325
Practice Address - Country:US
Practice Address - Phone:423-778-9001
Practice Address - Fax:423-778-4692
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20790363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care