Basic Information
| Provider Information | |||||||||
| NPI: | 1134380223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLELLAN | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MARIE KANDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANDRA | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8116 GOOD LUCK RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015525500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8116 GOOD LUCK RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015525500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116017376 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208100000X | D0069137 | MD | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 0101245599 | VA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.