Healthcare Provider Details

I. General information

NPI: 1790199628
Provider Name (Legal Business Name): CASEY LAURA CLEVELAND FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 COLLEGE HILL RD
CLINTON NY
13323-1218
US

IV. Provider business mailing address

198 COLLEGE HILL RD
CLINTON NY
13323-1218
US

V. Phone/Fax

Practice location:
  • Phone: 315-859-4111
  • Fax:
Mailing address:
  • Phone: 315-859-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33338815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: