Basic Information
| Provider Information | |||||||||
| NPI: | 1992242770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEVELAND | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534914 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 GREY LAG WAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405092477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633822 | ||||||||
| FaxNumber: | 8592633823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2017 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011079 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.