Healthcare Provider Details

I. General information

NPI: 1629180815
Provider Name (Legal Business Name): MS. CHARLOTTE A MCCLELLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 ASHRIDGE PL
RIDGELAND MS
39157-4136
US

IV. Provider business mailing address

404 ASHRIDGE PL
RIDGELAND MS
39157-4136
US

V. Phone/Fax

Practice location:
  • Phone: 601-898-1472
  • Fax:
Mailing address:
  • Phone: 601-898-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR784906
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: