MEDICARE: AMY RENEE MCCLELLAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist		TN

General Provider Information

NPI Number	:	1417734971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY RENEE MCCLELLAN

Provider Business Mailing Address
First Line	:	3014 OLD HORN LAKE RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38109-2757
Country	:	US
Telephone Number	:	901-859-7846
Fax Number	:

Provider Business Practice Location Address
First Line	:	3014 OLD HORN LAKE RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38109-2757
Country	:	US
Telephone Number	:	901-859-7846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	09/08/2023

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