MEDICARE: MRS. NICOLE MICHELLE CAVANAUGH LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA102951	FL

General Provider Information

NPI Number	:	1982457032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE MICHELLE CAVANAUGH LMT

Provider Business Mailing Address
First Line	:	2317 BRIDGEWATER CT
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-8615
Country	:	US
Telephone Number	:	904-226-8744
Fax Number	:

Provider Business Practice Location Address
First Line	:	1835 EASTWEST PKWY STE 3
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32003-5310
Country	:	US
Telephone Number	:	904-264-3770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2024
Last Update Date	:	04/09/2024

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