Provider Demographics
NPI:1861599045
Name:CLEVENGER, GINA P (C-FNP)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:P
Last Name:CLEVENGER
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:20 COLLINS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2486
Mailing Address - Country:US
Mailing Address - Phone:770-607-0795
Mailing Address - Fax:770-607-1339
Practice Address - Street 1:330 TURNER MCCALL BLVD SW STE 107
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5631
Practice Address - Country:US
Practice Address - Phone:706-509-6439
Practice Address - Fax:770-607-1339
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN120899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000836382BMedicaid
GA05-0523421OtherTIN