Healthcare Provider Details

I. General information

NPI: 1356162226
Provider Name (Legal Business Name): KATRINA ANN CAVANAUGH APRN-CNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 N MERRITT CREEK LOOP STE A
COEUR D ALENE ID
83814-4961
US

IV. Provider business mailing address

188 BIRCH AVE
PONDERAY ID
83852-7007
US

V. Phone/Fax

Practice location:
  • Phone: 208-819-2183
  • Fax: 208-209-6063
Mailing address:
  • Phone: 208-597-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2861171
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: