Healthcare Provider Details

I. General information

NPI: 1588032775
Provider Name (Legal Business Name): AMANDA CAVANAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-6250
  • Fax:
Mailing address:
  • Phone: 231-935-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1-115133
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number904262
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: