Provider Demographics
NPI:1932408788
Name:KAVANAGH, CONNIE JEAN (RN)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:JEAN
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 PYRITES RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:NY
Mailing Address - Zip Code:13652-3112
Mailing Address - Country:US
Mailing Address - Phone:315-386-2631
Mailing Address - Fax:
Practice Address - Street 1:1285 PYRITES RUSSELL RD
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:NY
Practice Address - Zip Code:13652-3112
Practice Address - Country:US
Practice Address - Phone:315-386-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY509704-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse