Provider Demographics
NPI:1639951643
Name:MCCLELLAN, COREEN LYN (NP)
Entity Type:Individual
Prefix:
First Name:COREEN
Middle Name:LYN
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 1:2337 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-9008
Mailing Address - Country:US
Mailing Address - Phone:970-701-9217
Mailing Address - Fax:
Practice Address - Street 1:2337 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-9008
Practice Address - Country:US
Practice Address - Phone:970-701-9217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13528242-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily