Provider Demographics
NPI:1073260469
Name:KAVANAGH, ALLISON KARINE
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:KARINE
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E CEDAR AVE STE A-3
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1630
Mailing Address - Country:US
Mailing Address - Phone:928-774-2788
Mailing Address - Fax:928-774-0123
Practice Address - Street 1:1515 E CEDAR AVE STE A-3
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1630
Practice Address - Country:US
Practice Address - Phone:928-774-2788
Practice Address - Fax:928-774-0123
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ271887363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily