Basic Information
| Provider Information | |||||||||
| NPI: | 1386649663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 46440 BENEDICT DR | ||||||||
| Address2: | STE 207 | ||||||||
| City: | STERLING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201646602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034442100 | ||||||||
| FaxNumber: | 7034440386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 0024164032 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1386649663 | 05 | VA | MEDICAID |