Provider Demographics
NPI:1104950088
Name:CLEVELAND, MINNIE MAXINE (RN)
Entity type:Individual
Prefix:
First Name:MINNIE
Middle Name:MAXINE
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:PALMETTO HEALTH RICHLAND - DIABETES EDUCATION
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6863
Mailing Address - Country:US
Mailing Address - Phone:803-434-7027
Mailing Address - Fax:803-434-1239
Practice Address - Street 1:9 RICHLAND MEDICAL PARK - SUITE 305
Practice Address - Street 2:PALMETTO HEALTH RICHLAND - DIABETES EDUCATION
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-7027
Practice Address - Fax:803-434-1239
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR41003163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDPE012Medicaid