Provider Demographics
NPI:1689421364
Name:BUSHNELL, KAVANAGH-FAYE MARIE (DO)
Entity type:Individual
Prefix:
First Name:KAVANAGH-FAYE
Middle Name:MARIE
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KAVANAGH-FAYE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:12204 WEDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-8498
Mailing Address - Country:US
Mailing Address - Phone:808-753-1973
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider