Provider Demographics
NPI:1699095851
Name:MECKLENBURG, JANICE M (CNP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:MECKLENBURG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17876 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2602
Mailing Address - Country:US
Mailing Address - Phone:216-383-2222
Mailing Address - Fax:216-298-0241
Practice Address - Street 1:17876 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2602
Practice Address - Country:US
Practice Address - Phone:216-383-2222
Practice Address - Fax:216-298-0241
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11462-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3052217Medicaid
OH3052217Medicaid
OHP00880294OtherRAILROAD MEDICARE