Provider Demographics
NPI:1932876539
Name:GAVAN, KERRI (LPN)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:GAVAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 SINGINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2826
Mailing Address - Country:US
Mailing Address - Phone:631-404-7278
Mailing Address - Fax:
Practice Address - Street 1:24 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-5042
Practice Address - Country:US
Practice Address - Phone:516-293-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341035164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse