Healthcare Provider Details

I. General information

NPI: 1316292477
Provider Name (Legal Business Name): JERRY LEE MCCLELLAN II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

PO BOX 3466
CHARLESTON WV
25334-3466
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6261
  • Fax:
Mailing address:
  • Phone: 304-720-8816
  • Fax: 904-494-6467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number88050
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN64260
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: