Provider Demographics
NPI:1619584646
Name:CLEVELAND, DERRICK R (RN)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:R
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S PALMWAY APT 3
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-4282
Mailing Address - Country:US
Mailing Address - Phone:561-502-0637
Mailing Address - Fax:
Practice Address - Street 1:132 S PALMWAY APT 3
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-4282
Practice Address - Country:US
Practice Address - Phone:561-502-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9477206163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse