MEDICARE: AUTUMN MCCLELLAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	CNP251127	ME
2	163W00000X	Registered Nurse	201505014RN	OR
3	363LF0000X	Family Nurse Practitioner	202107827NP-PP	OR

General Provider Information

NPI Number	:	1720656655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN MCCLELLAN FNP

Provider Business Mailing Address
First Line	:	307 S EVERGREEN AVE
Second Line	:
City	:	WOODBURY
State	:	NJ
Zip	:	08096-2739
Country	:	US
Telephone Number	:	856-686-4393
Fax Number	:	856-694-5179

Provider Business Practice Location Address
First Line	:	1990 NW 21ST ST
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-6769
Country	:	US
Telephone Number	:	503-752-2838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2021
Last Update Date	:	04/07/2026

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