Provider Demographics
NPI:1841583804
Name:MCCLELLAN, TERESA (IBCLC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 KING ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4754
Mailing Address - Country:US
Mailing Address - Phone:404-273-2223
Mailing Address - Fax:
Practice Address - Street 1:164 KING ARTHUR DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4754
Practice Address - Country:US
Practice Address - Phone:404-273-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11014410174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN