Provider Demographics
NPI:1285305870
Name:VAN CLEAVE, MISTY (DNP FNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:VAN CLEAVE
Suffix:
Gender:F
Credentials:DNP FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7103 SE SHERRETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-8727
Mailing Address - Country:US
Mailing Address - Phone:503-545-7213
Mailing Address - Fax:
Practice Address - Street 1:LEGACY GOHEALTH URGENT CARE GRESHAM
Practice Address - Street 2:2850 SE POWELL VALLEY RD., STE. 100
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080
Practice Address - Country:US
Practice Address - Phone:505-050-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202110509NP-PP363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program