1316478969 NPI number — MRS. SHANTEA ANGELIC JULIAN MCCLELLAN M.S.

Table of content: MRS. SHANTEA ANGELIC JULIAN MCCLELLAN M.S. (NPI 1316478969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316478969 NPI number — MRS. SHANTEA ANGELIC JULIAN MCCLELLAN M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLELLAN
Provider First Name:
SHANTEA
Provider Middle Name:
ANGELIC JULIAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316478969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 SOUTHAMPTON RD APT 145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENICIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94510-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-592-3774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3419 VALLE VERDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558-2414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-721-2060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com