Basic Information
| Provider Information | |||||||||
| NPI: | 1669707287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVANAGH | ||||||||
| FirstName: | ELLYN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PHD, MN, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4430 106TH ST SW | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982754711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254396002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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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 | 363L00000X | AP30002468 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 061473-23 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2034048 | 05 | WA | MEDICAID | 30347751 | 05 | NH | MEDICAID | 1016889 | 05 | VT | MEDICAID |