Provider Demographics
NPI:1659494730
Name:MCLELLAN, MARION M (RD)
Entity Type:Individual
Prefix:MS
First Name:MARION
Middle Name:M
Last Name:MCLELLAN
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 1:897 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-1029
Mailing Address - Country:US
Mailing Address - Phone:207-564-4255
Mailing Address - Fax:
Practice Address - Street 1:897 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1029
Practice Address - Country:US
Practice Address - Phone:207-564-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI18133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
METMP PEC -0021Medicare ID - Type UnspecifiedPROVIDER NUMBER