Healthcare Provider Details

I. General information

NPI: 1245273598
Provider Name (Legal Business Name): PEGGY J MCCLELLAN DIETITAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-7850
  • Fax: 801-357-7997
Mailing address:
  • Phone: 801-357-7475
  • Fax: 801-357-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1021324901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: