Provider Demographics
NPI:1114602174
Name:CANTRELL, ELVONDA JEAN
Entity Type:Individual
Prefix:
First Name:ELVONDA
Middle Name:JEAN
Last Name:CANTRELL
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 1:6240 W CHINOOK CT
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89433-6622
Mailing Address - Country:US
Mailing Address - Phone:775-741-0027
Mailing Address - Fax:
Practice Address - Street 1:250 VISTA KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-5594
Practice Address - Country:US
Practice Address - Phone:775-332-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV439156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty