Provider Demographics
NPI:1639400088
Name:MCCLELLAN, AMY J (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03802-1102
Mailing Address - Country:US
Mailing Address - Phone:603-828-5188
Mailing Address - Fax:207-703-0454
Practice Address - Street 1:202 BOLT HILL RD
Practice Address - Street 2:
Practice Address - City:ELIOT
Practice Address - State:ME
Practice Address - Zip Code:03903-1932
Practice Address - Country:US
Practice Address - Phone:603-828-5188
Practice Address - Fax:207-703-0454
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI935133V00000X
NH555133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered