Basic Information
| Provider Information | |||||||||
| NPI: | 1124087697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANCLEVE | ||||||||
| FirstName: | CRISTIN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27-408 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641800001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164618288 | ||||||||
| FaxNumber: | 8164616586 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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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 | 367500000X | 074366 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 912675311 | 05 | MO | MEDICAID |