Provider Demographics
NPI:1386649663
Name:CANTRELL, JAN W (CPNP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:W
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:CPNP
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 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:46440 BENEDICT DR
Practice Address - Street 2:STE 207
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:703-444-2100
Practice Address - Fax:703-444-0386
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164032363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1386649663Medicaid