Basic Information
| Provider Information | |||||||||
| NPI: | 1184895401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEAVELAND | ||||||||
| FirstName: | KAREN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 KANE ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061192110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605236421 | ||||||||
| FaxNumber: | 8605233701 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606793105 | ||||||||
| FaxNumber: | 8606791403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 04/05/2013 | ||||||||
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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 | 363LF0000X | 002047 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LN0000X | 2047 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 002047 | 01 | CT | CT LICENSE | OTHER | 1184895401 | 05 | CT | MEDICAID |