Provider Demographics
NPI:1184895401
Name:CLEAVELAND, KAREN (APRN)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:CLEAVELAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 KANE ST
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-6421
Mailing Address - Fax:860-523-3701
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2948
Practice Address - Country:US
Practice Address - Phone:860-679-3105
Practice Address - Fax:860-679-1403
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002047363LF0000X
CT2047363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002047OtherCT LICENSE
CT1184895401Medicaid
CT1184895401Medicaid