Provider Demographics
NPI:1114433851
Name:CAVANAUGH, KELLY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BATTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2270 MEADOWLAKE RD APT 803
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-2676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2302 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6297
Practice Address - Country:US
Practice Address - Phone:501-513-5286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered