Healthcare Provider Details

I. General information

NPI: 1164461810
Provider Name (Legal Business Name): NINA ANN CAVALLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5027 VANTAGE CT
SAINT CLOUD FL
34772-7564
US

IV. Provider business mailing address

5027 VANTAGE CT
SAINT CLOUD FL
34772-7564
US

V. Phone/Fax

Practice location:
  • Phone: 201-693-7034
  • Fax: 201-768-3840
Mailing address:
  • Phone: 201-693-7034
  • Fax: 201-768-3840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME143314
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06395900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: