MEDICARE: MS. MADISON LEIGH KLAVAN

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	1059920	TX

General Provider Information

NPI Number	:	1477299766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MADISON LEIGH KLAVAN

Provider Business Mailing Address
First Line	:	1690 W LANE AVE UNIT 401
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-2588
Country	:	US
Telephone Number	:	405-820-0029
Fax Number	:

Provider Business Practice Location Address
First Line	:	1690 W LANE AVE UNIT 401
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-2588
Country	:	US
Telephone Number	:	405-820-0029
Fax Number	:

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

Provider Enumeration Date	:	05/09/2022
Last Update Date	:	10/06/2022

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