Healthcare Provider Details

I. General information

NPI: 1477299766
Provider Name (Legal Business Name): MS. MADISON LEIGH KLAVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 W LANE AVE UNIT 401
COLUMBUS OH
43221-2588
US

IV. Provider business mailing address

1690 W LANE AVE UNIT 401
COLUMBUS OH
43221-2588
US

V. Phone/Fax

Practice location:
  • Phone: 405-820-0029
  • Fax:
Mailing address:
  • Phone: 405-820-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number1059920
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: