Provider Demographics
NPI:1740987437
Name:MCCLELLAN, TISHA
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:MCCLELLAN
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 1:1450 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7207
Mailing Address - Country:US
Mailing Address - Phone:417-559-9860
Mailing Address - Fax:
Practice Address - Street 1:1450 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7207
Practice Address - Country:US
Practice Address - Phone:417-559-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOJ071099002172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver