Healthcare Provider Details

I. General information

NPI: 1447401500
Provider Name (Legal Business Name): NICOLE LEE MCCLELLAND APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 GOLF VIEW DR SUITE # 200
MEDFORD OR
97504-9685
US

IV. Provider business mailing address

760 GOLF VIEW DR SUITE # 200
MEDFORD OR
97504-9685
US

V. Phone/Fax

Practice location:
  • Phone: 541-618-4400
  • Fax: 541-618-4406
Mailing address:
  • Phone: 541-618-4400
  • Fax: 541-618-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1824
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201050102NP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number110995
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: