Provider Demographics
NPI:1124224746
Name:MCCLELLAN, WANDA RENEE (APN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:RENEE
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 851
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:AR
Mailing Address - Zip Code:71744-0851
Mailing Address - Country:US
Mailing Address - Phone:870-798-4299
Mailing Address - Fax:870-798-2005
Practice Address - Street 1:402 SOUTH LEE STREET
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:AR
Practice Address - Zip Code:71744-0851
Practice Address - Country:US
Practice Address - Phone:870-798-4299
Practice Address - Fax:870-798-2005
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01769363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARQ22588Medicare UPIN