Provider Demographics
NPI:1285901553
Name:CLEAVENGER, NICHOLE (CRNA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CLEAVENGER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:VINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1540 PENINSULA CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6623
Mailing Address - Country:US
Mailing Address - Phone:313-347-3788
Mailing Address - Fax:
Practice Address - Street 1:5300 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8632
Practice Address - Country:US
Practice Address - Phone:734-434-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.354451163W00000X
OHCOA.12963367500000X
MI4704259222367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse