Healthcare Provider Details

I. General information

NPI: 1578950077
Provider Name (Legal Business Name): DONNA L MCLEAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MAGNOLIA AVE SUITE A
BRIDGETON NJ
08302-1759
US

IV. Provider business mailing address

PO BOX 64
FAIRTON NJ
08320-0064
US

V. Phone/Fax

Practice location:
  • Phone: 856-455-7017
  • Fax: 856-455-2594
Mailing address:
  • Phone: 856-455-7017
  • Fax: 856-455-2594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number25ME00010601
License Number StateNJ

VIII. Authorized Official

Name: MRS. DONNA L MCLEAN
Title or Position: OWNER
Credential: CNM
Phone: 856-455-7017