Provider Demographics
NPI:1669707287
Name:CAVANAGH, ELLYN ELIZABETH (PHD, MN, APRN)
Entity type:Individual
Prefix:MS
First Name:ELLYN
Middle Name:ELIZABETH
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:PHD, MN, APRN
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:4430 106TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-4711
Practice Address - Country:US
Practice Address - Phone:425-439-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002468363L00000X
NH061473-23363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034048Medicaid
NH30347751Medicaid
VT1016889Medicaid
NH30347751Medicaid
WAG8933436Medicare PIN