Provider Demographics
NPI:1861629735
Name:CLEVELAND, GINA MAUREEN (LVN, LPN)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MAUREEN
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:LVN, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 BALLYMORE PASS
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-7418
Mailing Address - Country:US
Mailing Address - Phone:559-760-8641
Mailing Address - Fax:
Practice Address - Street 1:417 BALLYMORE PASS
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-7418
Practice Address - Country:US
Practice Address - Phone:559-760-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAVN237459164X00000X
GALPN090192164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No164X00000XNursing Service ProvidersLicensed Vocational Nurse