Provider Demographics
NPI:1982074068
Name:CAVANAGH, CELINA
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW 1ST AVE
Mailing Address - Street 2:APT 1505
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3476
Mailing Address - Country:US
Mailing Address - Phone:561-504-9254
Mailing Address - Fax:
Practice Address - Street 1:201 NW 82ND AVE
Practice Address - Street 2:405
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-7808
Practice Address - Country:US
Practice Address - Phone:954-614-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109101363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty