Healthcare Provider Details

I. General information

NPI: 1659911998
Provider Name (Legal Business Name): KASEY E KAVANAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

PO BOX 670634
CHUGIAK AK
99567-0634
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-3344
  • Fax:
Mailing address:
  • Phone: 907-440-6338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number61034037
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: