Basic Information
| Provider Information | |||||||||
| NPI: | 1912448937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAVANAUGH | ||||||||
| FirstName: | ALANNA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLOCK TOWER CMNS | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105094055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455924915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 E 61ST ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6469622333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 08/16/2019 | ||||||||
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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 | 363LF0000X | 341680 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 04824700 | 05 | NY | MEDICAID |