Provider Demographics
NPI:1699246199
Name:KAVANAGH, JILLIAN LUCEY (NP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LUCEY
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2301
Mailing Address - Country:US
Mailing Address - Phone:978-808-5476
Mailing Address - Fax:
Practice Address - Street 1:4 CENTENNIAL DR STE 204
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7930
Practice Address - Country:US
Practice Address - Phone:978-977-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264536163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse