Healthcare Provider Details

I. General information

NPI: 1285305870
Provider Name (Legal Business Name): MISTY VAN CLEAVE DNP FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 11/21/2021
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LEGACY GOHEALTH URGENT CARE GRESHAM 2850 SE POWELL VALLEY RD., STE. 100
GRESHAM OR
97080
US

IV. Provider business mailing address

7103 SE SHERRETT ST
PORTLAND OR
97206-8727
US

V. Phone/Fax

Practice location:
  • Phone: 505-050-3666
  • Fax:
Mailing address:
  • Phone: 503-545-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202110509NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: