Provider Demographics
NPI:1811538770
Name:CAVANAUGH, SHANNON (NMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 PEGASUS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-3272
Mailing Address - Country:US
Mailing Address - Phone:702-235-9985
Mailing Address - Fax:
Practice Address - Street 1:2550 PEGASUS DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-3272
Practice Address - Country:US
Practice Address - Phone:702-235-9985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK191955175F00000X
AZ19-1820175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath