MEDICARE: ELLEN CAVANAUGH APRN

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	363LG0600X	Gerontology Nurse Practitioner	RN-044483	AZ

General Provider Information

NPI Number	:	1205983608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN CAVANAUGH APRN

Provider Business Mailing Address
First Line	:	819 W LODGE DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-3570
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3141 N 3RD AVE
Second Line	:	AZ9501000
City	:	PHOENIX
State	:	AZ
Zip	:	85013-4351
Country	:	US
Telephone Number	:	602-745-7925
Fax Number	:

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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