Provider Demographics
NPI:1699794271
Name:MCCLELLAN, MELISSA A (CNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2357 108TH LN NE
Mailing Address - Street 2:MN002
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5222
Mailing Address - Country:US
Mailing Address - Phone:763-232-0323
Mailing Address - Fax:
Practice Address - Street 1:2357 108TH LN NE
Practice Address - Street 2:MN002
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5222
Practice Address - Country:US
Practice Address - Phone:763-232-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF0605160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00320152OtherMEDICARE RAILROAD
MN01-21788OtherMEDICA
MN283P8MCOtherBLUE CROSS BLUE SHIELD
MN265443100Medicaid
MN500003680Medicare Oscar/Certification
MN283P8MCOtherBLUE CROSS BLUE SHIELD
MN01-21788OtherMEDICA