Provider Demographics
NPI:1902124449
Name:CLEVELAND, PENNY S (LPN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:S
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6941 STATE ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:BOUCKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13310-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6941 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:BOUCKVILLE
Practice Address - State:NY
Practice Address - Zip Code:13310-1623
Practice Address - Country:US
Practice Address - Phone:315-351-0941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190682-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse