Provider Demographics
NPI:1245979905
Name:KAVANAUGH, COLETTE AUGUSTINA (LE)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:AUGUSTINA
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-3114
Mailing Address - Country:US
Mailing Address - Phone:916-838-8240
Mailing Address - Fax:
Practice Address - Street 1:1721 EASTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-1745
Practice Address - Country:US
Practice Address - Phone:916-838-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9736247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty