Provider Demographics
NPI:1962827345
Name:KAVANAUGH, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:KAVANAUGH
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 1:4144 WYNTREE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2521
Mailing Address - Country:US
Mailing Address - Phone:812-858-1957
Mailing Address - Fax:812-858-1917
Practice Address - Street 1:4144 WYNTREE DR
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2521
Practice Address - Country:US
Practice Address - Phone:812-858-1957
Practice Address - Fax:812-858-1917
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004829A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily