Healthcare Provider Details

I. General information

NPI: 1831870450
Provider Name (Legal Business Name): ALEXANDRIA CAVARETTA GREEN APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 S ACADEMY LN
EAGLE ID
83616-7470
US

IV. Provider business mailing address

367 S ACADEMY LN
EAGLE ID
83616-7470
US

V. Phone/Fax

Practice location:
  • Phone: 985-778-7582
  • Fax:
Mailing address:
  • Phone: 985-778-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75938
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: