Basic Information
| Provider Information | |||||||||
| NPI: | 1013406412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEVELAND | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SPECIAL OPERATIONS MEDICAL GROUP 113 LIELMANIS AVE | ||||||||
| Address2: | |||||||||
| City: | HURLBURT FIELD AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32544 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SPECIAL OPERATIONS MEDICAL GROUP AT113 LIELMANIS AVE | ||||||||
| Address2: | |||||||||
| City: | HURLBURT FIELD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325445613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2018 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | 30.025375 | OH | Y | Dental Providers | Dentist | General Practice |
No ID Information.