Provider Demographics
NPI:1710748710
Name:CLEVELAND, DYMONDE (CHW1-5647)
Entity Type:Individual
Prefix:
First Name:DYMONDE
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:CHW1-5647
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3640
Mailing Address - Country:US
Mailing Address - Phone:909-238-7077
Mailing Address - Fax:
Practice Address - Street 1:800 N RAINBOW BLVD STE 165
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:702-213-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCHW1-5647172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty