Provider Demographics
NPI:1821058306
Name:KAVANAUGH, KATHERINE (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1824
Mailing Address - Country:US
Mailing Address - Phone:319-369-4505
Mailing Address - Fax:319-369-4677
Practice Address - Street 1:600 7TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-2112
Practice Address - Country:US
Practice Address - Phone:319-221-8800
Practice Address - Fax:319-221-8787
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078725363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0470948Medicaid
I16967Medicare PIN
IA0470948Medicaid