Provider Demographics
NPI:1053029660
Name:CAVANAUGH, ANTRIONNA
Entity type:Individual
Prefix:
First Name:ANTRIONNA
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350415
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43635-0415
Mailing Address - Country:US
Mailing Address - Phone:419-764-7668
Mailing Address - Fax:
Practice Address - Street 1:1800 N MCCORD RD APT 45
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-3091
Practice Address - Country:US
Practice Address - Phone:419-764-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness