Provider Demographics
NPI:1477337061
Name:CAVANAUGH, AMY (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:PAULUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-5022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 WALTON DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5022
Practice Address - Country:US
Practice Address - Phone:920-892-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14309-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100252605Medicaid