Provider Demographics
NPI:1851424642
Name:MCCLELLAN, DEBRA (LDN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MED TECH PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2364
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-0720
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-0720
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0298133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNC30809Medicare PIN
TNPENDINGMedicare UPIN
TNPENDINGMedicare ID - Type Unspecified
TNPENDINGMedicaid
TNP00243017Medicare PIN