Provider Demographics
NPI:1316149818
Name:CAVALLO, MARTHA ANNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ANNE
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W END AVE
Mailing Address - Street 2:APT 4 B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1037
Mailing Address - Country:US
Mailing Address - Phone:617-957-4231
Mailing Address - Fax:
Practice Address - Street 1:722 W 168TH ST
Practice Address - Street 2:SUITE 820
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3727
Practice Address - Country:US
Practice Address - Phone:866-463-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5637831363LW0102X
NYF382276-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health