Provider Demographics
NPI:1295328672
Name:MCCLELLAN, SHANTONIA NAQUITA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:SHANTONIA
Middle Name:NAQUITA
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29756 CITY CENTER DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2426
Mailing Address - Country:US
Mailing Address - Phone:313-467-3565
Mailing Address - Fax:
Practice Address - Street 1:29756 CITY CENTER DR APT 4
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2426
Practice Address - Country:US
Practice Address - Phone:313-467-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704349797163WG0000X, 163WH0200X, 163WI0500X, 163WS0200X, 163WW0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WW0000XNursing Service ProvidersRegistered NurseWound Care