Provider Demographics
NPI:1710282512
Name:CAVANAUGH, MELISSA GAIL (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GAIL
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUILDING 301 ANDREWS AVE.
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330
Mailing Address - Country:US
Mailing Address - Phone:334-379-5249
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 301 ANDREWS AVE.
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FT. RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-064153163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse