Provider Demographics
NPI:1073075586
Name:KLEVELAND, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KLEVELAND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-3835
Mailing Address - Country:US
Mailing Address - Phone:402-239-3109
Mailing Address - Fax:
Practice Address - Street 1:320 N 5TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2957
Practice Address - Country:US
Practice Address - Phone:402-223-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68178163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE68178OtherREGISTERED NURSE