Provider Demographics
NPI:1760984454
Name:KLAVERWEIDEN, PAUL ELWOOD JR (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ELWOOD
Last Name:KLAVERWEIDEN
Suffix:JR
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21826-0010
Mailing Address - Country:US
Mailing Address - Phone:410-831-3899
Mailing Address - Fax:443-210-2786
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:MD
Practice Address - Zip Code:21826-1604
Practice Address - Country:US
Practice Address - Phone:410-831-3899
Practice Address - Fax:410-210-2786
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173574363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health