MEDICARE: MARY ANN CLEVENGER NURSE PRACTIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1039114	KY

General Provider Information

NPI Number	:	1093443491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ANN CLEVENGER NURSE PRACTIONER

Provider Business Mailing Address
First Line	:	2643 APPLING GLEN DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-5228
Country	:	US
Telephone Number	:	901-849-1722
Fax Number	:

Provider Business Practice Location Address
First Line	:	2643 APPLING GLEN DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-5228
Country	:	US
Telephone Number	:	901-849-1722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2022
Last Update Date	:	08/12/2022

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