Provider Demographics
NPI:1144538489
Name:KAVANAGH, DIANA M
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:M
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:M
Other - Last Name:KAVANAGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:345 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2348
Mailing Address - Country:US
Mailing Address - Phone:203-752-2856
Mailing Address - Fax:203-752-8785
Practice Address - Street 1:345 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2348
Practice Address - Country:US
Practice Address - Phone:203-366-0664
Practice Address - Fax:203-752-8785
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily