Basic Information
| Provider Information | |||||||||
| NPI: | 1861599045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEVENGER | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | C-FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 COLLINS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 TURNER MCCALL BLVD SW STE 107 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301655631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065096439 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN120899 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000836382B | 05 | GA | MEDICAID |