Provider Demographics
NPI:1538100789
Name:CANTRELL, WENDY CLEMONS (CRNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:CLEMONS
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2900 CAHABA RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-1937
Practice Address - Country:US
Practice Address - Phone:205-877-9773
Practice Address - Fax:205-877-9775
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-079199363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000099306Medicaid
ALP22346OtherVIVA
AL000099306OtherBLUE CROSS
AL000099306Medicaid