Healthcare Provider Details

I. General information

NPI: 1699246199
Provider Name (Legal Business Name): JILLIAN LUCEY KAVANAGH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2018
Last Update Date: 12/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CENTENNIAL DR STE 204
PEABODY MA
01960-7930
US

IV. Provider business mailing address

321 ESSEX AVE
GLOUCESTER MA
01930-2301
US

V. Phone/Fax

Practice location:
  • Phone: 978-977-0351
  • Fax:
Mailing address:
  • Phone: 978-808-5476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2264536
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2264536
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: