Healthcare Provider Details

I. General information

NPI: 1548418189
Provider Name (Legal Business Name): MEGHAN TOOKE KAVANAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 S VIENNA ST
RUSTON LA
71270-5845
US

IV. Provider business mailing address

707 S VIENNA ST
RUSTON LA
71270-5845
US

V. Phone/Fax

Practice location:
  • Phone: 183-224-3044
  • Fax: 318-232-2978
Mailing address:
  • Phone: 318-224-3044
  • Fax: 318-232-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number2108
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2108
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2108
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2108
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number2108
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number2108
License Number StateLA
# 7
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number206952
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: