Healthcare Provider Details

I. General information

NPI: 1255531638
Provider Name (Legal Business Name): NANCY ALEXANDRIA CAVANAUGH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3617 S PACIFIC HWY
MEDFORD OR
97501-8957
US

IV. Provider business mailing address

859 WHITE OAK AVE
CENTRAL POINT OR
97502-3608
US

V. Phone/Fax

Practice location:
  • Phone: 541-535-6239
  • Fax: 541-512-1026
Mailing address:
  • Phone: 541-423-5332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number201142758RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number201250005NP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number220
License Number StateAK
# 4
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number201250005NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: