Provider Demographics
NPI:1881204816
Name:CORUM, MCLELLAN JANE
Entity Type:Individual
Prefix:
First Name:MCLELLAN
Middle Name:JANE
Last Name:CORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 BATTLEGROUND AVE APT 32
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9433
Mailing Address - Country:US
Mailing Address - Phone:336-609-3129
Mailing Address - Fax:
Practice Address - Street 1:1400 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27412-5015
Practice Address - Country:US
Practice Address - Phone:336-334-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty