Provider Demographics
NPI:1306353321
Name:MCLELLAN, DONNA MARIE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02188-3404
Mailing Address - Country:US
Mailing Address - Phone:617-653-3784
Mailing Address - Fax:
Practice Address - Street 1:20 ELLEN AVE
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02188-3404
Practice Address - Country:US
Practice Address - Phone:617-653-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2017-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN172136363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health