Provider Demographics
NPI:1477219020
Name:KAVANAGHT, LAETITIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LAETITIA
Middle Name:
Last Name:KAVANAGHT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BRONXVILLE RD APT 2F
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-6134
Mailing Address - Country:US
Mailing Address - Phone:914-433-3735
Mailing Address - Fax:
Practice Address - Street 1:15 BRONXVILLE RD APT 2F
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-6134
Practice Address - Country:US
Practice Address - Phone:914-433-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348799363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner