1154171916 NPI number — ALLISON KATHERINE KAVANAGH RD, LDN

Table of content: ALLISON KATHERINE KAVANAGH RD, LDN (NPI 1154171916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154171916 NPI number — ALLISON KATHERINE KAVANAGH RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAVANAGH
Provider First Name:
ALLISON
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FASSLER
Provider Other First Name:
ALLISON
Provider Other Middle Name:
KATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154171916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3902 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61081-9412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-213-0142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3902 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61081-9412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-213-0142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  164.007066 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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