Provider Demographics
NPI:1770598559
Name:GAVIN, KATHY (FNP)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30410 HIGHWAY 200
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9601
Mailing Address - Country:US
Mailing Address - Phone:208-263-1345
Mailing Address - Fax:208-255-5531
Practice Address - Street 1:30410 HIGHWAY 200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9601
Practice Address - Country:US
Practice Address - Phone:208-263-1345
Practice Address - Fax:208-255-5531
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-257A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1341497Medicare ID - Type Unspecified
IDR31453Medicare UPIN