Basic Information
| Provider Information | |||||||||
| NPI: | 1902856776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVANAGH | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MSN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639035 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 HICKORY PARK DR STE A | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230592623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042626060 | ||||||||
| FaxNumber: | 8042626422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024168749 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 0024168749 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.