Provider Demographics
NPI:1417405267
Name:CAVIN, KERRI RAE (AG ACNP-BC)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:RAE
Last Name:CAVIN
Suffix:
Gender:F
Credentials:AG ACNP-BC
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:RAE
Other - Last Name:VARTAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY AVE
Mailing Address - Street 2:SUITE 65B #259
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-576-3525
Mailing Address - Fax:209-576-3544
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-576-3525
Practice Address - Fax:209-576-3544
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004803363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care