Provider Demographics
NPI:1952952939
Name:MCCLAMROCH, MEGAN LEILANI
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEILANI
Last Name:MCCLAMROCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LEILANI
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:1630 LAFAYETTE RD STE 200
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1092
Practice Address - Country:US
Practice Address - Phone:765-359-2230
Practice Address - Fax:765-359-2236
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28193277A363LA2200X
IN71010134A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health