Healthcare Provider Details

I. General information

NPI: 1720717549
Provider Name (Legal Business Name): MOLLY KATE CAVANAUGH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9263 MEDICAL PLAZA DR STE E
CHARLESTON SC
29406-7112
US

IV. Provider business mailing address

71 WARREN ST
CHARLESTON SC
29403-6122
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-1228
  • Fax:
Mailing address:
  • Phone: 434-960-9668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number29035
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number111137
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: