1912088634 NPI number — MS. ALYSSA C MCCLELLAND FNP

Table of content: MS. ALYSSA C MCCLELLAND FNP (NPI 1912088634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912088634 NPI number — MS. ALYSSA C MCCLELLAND FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLELLAND
Provider First Name:
ALYSSA
Provider Middle Name:
C
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1912088634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 2ND LOOP RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29501-6123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-678-9777
Provider Business Mailing Address Fax Number:
843-665-2814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 OKATIE CENTER BLVD S
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
OKATIE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29909-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-705-3800
Provider Business Practice Location Address Fax Number:
843-705-3840
Provider Enumeration Date:
10/18/2006

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: 363LF0000X , with the licence number:  3032 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP1082 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3032 . This is a "LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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