Healthcare Provider Details

I. General information

NPI: 1417405267
Provider Name (Legal Business Name): KERRI RAE CAVIN AG ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KERRI RAE VARTAN

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

1700 MCHENRY AVE SUITE 65B #259
MODESTO CA
95350
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3525
  • Fax: 209-576-3544
Mailing address:
  • Phone: 209-576-3525
  • Fax: 209-576-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP95004803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: