Provider Demographics
NPI:1073715322
Name:CLEAVENGER, MARCIA L (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:L
Last Name:CLEAVENGER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-4144
Mailing Address - Country:US
Mailing Address - Phone:785-452-6113
Mailing Address - Fax:785-452-6119
Practice Address - Street 1:400 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4144
Practice Address - Country:US
Practice Address - Phone:785-452-6113
Practice Address - Fax:785-452-6119
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46036363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200441970CMedicaid