Basic Information
| Provider Information | |||||||||
| NPI: | 1255531638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVANAUGH | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | ALEXANDRIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 859 WHITE OAK AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975023608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414235332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3617 S PACIFIC HWY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975018957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415356239 | ||||||||
| FaxNumber: | 5415121026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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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 | 163WP0200X | 201142758RN | OR | N | Nursing Service Providers | Registered Nurse | Pediatrics | 163WP0200X | 201250005NP | OR | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | 220 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 201250005NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500648116 | 05 | OR | MEDICAID | R173833 | 01 | OR | MEDICARE PTAN | OTHER | NP13731 | 05 | AK | MEDICAID |