Provider Demographics
NPI:1356162226
Name:CAVANAUGH, KATRINA ANN (APRN-CNP, RN)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANN
Last Name:CAVANAUGH
Suffix:
Gender:
Credentials:APRN-CNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-7007
Mailing Address - Country:US
Mailing Address - Phone:208-597-2508
Mailing Address - Fax:
Practice Address - Street 1:188 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-7007
Practice Address - Country:US
Practice Address - Phone:208-597-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-22
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2861171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily