Healthcare Provider Details

I. General information

NPI: 1851059307
Provider Name (Legal Business Name): MELISSA NICOLE CLEAVELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 W TRANSIT ST
FAYETTEVILLE AR
72704-5097
US

IV. Provider business mailing address

1722 RIDGEWOOD CIR
NEOSHO MO
64850-1394
US

V. Phone/Fax

Practice location:
  • Phone: 417-434-5898
  • Fax:
Mailing address:
  • Phone: 417-434-5898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2005022626
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: