Basic Information
| Provider Information | |||||||||
| NPI: | 1053682765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVA | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | ACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY STREET, JANE BROWN, 2 SOUTH | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445943 | ||||||||
| FaxNumber: | 4014444216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN34380 | RI | N | Nursing Service Providers | Registered Nurse | 363LA2100X | NPP37680 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.