Provider Demographics
NPI:1477299766
Name:KLAVAN, MADISON LEIGH
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:LEIGH
Last Name:KLAVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 W LANE AVE UNIT 401
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2588
Mailing Address - Country:US
Mailing Address - Phone:405-820-0029
Mailing Address - Fax:
Practice Address - Street 1:1690 W LANE AVE UNIT 401
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2588
Practice Address - Country:US
Practice Address - Phone:405-820-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1059920363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program