Healthcare Provider Details

I. General information

NPI: 1487809273
Provider Name (Legal Business Name): CYNTHIA MCCLELLAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON ST
TYLER TX
75701-2036
US

IV. Provider business mailing address

PO BOX 841656
DALLAS TX
75284-1656
US

V. Phone/Fax

Practice location:
  • Phone: 903-525-1913
  • Fax:
Mailing address:
  • Phone: 903-531-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number635040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: