1750898466 NPI number — MANDY CLEEK APRN, CRNA

Table of content: MANDY CLEEK APRN, CRNA (NPI 1750898466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750898466 NPI number — MANDY CLEEK APRN, CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEEK
Provider First Name:
MANDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANDERS
Provider Other First Name:
MANCY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750898466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRUETLI LAAGER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37339-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2341 MCCALLIE AVE STE 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37404-3231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-648-2720
Provider Business Practice Location Address Fax Number:
423-624-6355
Provider Enumeration Date:
01/03/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  23743 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)