Provider Demographics
NPI:1447601455
Name:CANTU, TANAKA (LPN)
Entity Type:Individual
Prefix:
First Name:TANAKA
Middle Name:
Last Name:CANTU
Suffix:
Gender:F
Credentials:LPN
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 1030
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-1030
Mailing Address - Country:US
Mailing Address - Phone:580-298-2830
Mailing Address - Fax:580-298-6723
Practice Address - Street 1:411 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6059
Practice Address - Country:US
Practice Address - Phone:580-286-7876
Practice Address - Fax:580-286-5721
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0052993164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse