Basic Information
| Provider Information | |||||||||
| NPI: | 1851424642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLELLAN | ||||||||
| FirstName: | DEBRA | ||||||||
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| Credential: | LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 MED TECH PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232820720 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232820720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 0298 | TN | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 0298 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | TN | MEDICAID |