Provider Demographics
NPI:1063497840
Name:CLEVELAND, KAYE M (ARNP)
Entity Type:Individual
Prefix:
First Name:KAYE
Middle Name:M
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KAYE
Other - Middle Name:M
Other - Last Name:GROSSNICKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:325 LOOMIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2416
Mailing Address - Country:US
Mailing Address - Phone:515-955-1836
Mailing Address - Fax:
Practice Address - Street 1:1728 CENTRAL AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4200
Practice Address - Country:US
Practice Address - Phone:515-955-1836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA063458363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA34971OtherWELLMARK BCBS
IAI10463Medicare PIN
IAS30050Medicare UPIN