Provider Demographics
NPI:1730815291
Name:CANAVAN, KIRSTEN (FNP)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10264 W PARKEDGE CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-1234
Mailing Address - Country:US
Mailing Address - Phone:570-862-9650
Mailing Address - Fax:
Practice Address - Street 1:W63N545 HANOVER AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1917
Practice Address - Country:US
Practice Address - Phone:262-421-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12101-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily