Provider Demographics
NPI:1780901314
Name:MCCLELLAN, CAROL DENISE
Entity type:Individual
Prefix:PROF
First Name:CAROL
Middle Name:DENISE
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 1:5535 HIGHLAND TRACE CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1760
Mailing Address - Country:US
Mailing Address - Phone:336-926-1643
Mailing Address - Fax:
Practice Address - Street 1:5535 HIGHLAND TRACE CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1760
Practice Address - Country:US
Practice Address - Phone:336-926-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10454347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle