Provider Demographics
NPI:1447506654
Name:CLEVENGER, CHRISTINE DANIELLE (PAAA)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:DANIELLE
Last Name:CLEVENGER
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:DANIELLE
Other - Last Name:BOYNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006595367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129214AMedicaid
GA003129214AMedicaid