Provider Demographics
NPI:1699221374
Name:CAVENDER, KAITLAIN
Entity Type:Individual
Prefix:
First Name:KAITLAIN
Middle Name:
Last Name:CAVENDER
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 1:430 STONE CUTTER DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4975
Mailing Address - Country:US
Mailing Address - Phone:815-954-7884
Mailing Address - Fax:
Practice Address - Street 1:430 STONE CUTTER DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4975
Practice Address - Country:US
Practice Address - Phone:815-954-7884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily