Provider Demographics
NPI:1790320448
Name:MCCAVANAGH, KIRSTEN
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:MCCAVANAGH
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 1:6737 WILBER CIR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-4865
Mailing Address - Country:US
Mailing Address - Phone:804-366-5352
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5058
Practice Address - Country:US
Practice Address - Phone:804-828-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178516363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care