Provider Demographics
NPI:1649384413
Name:CANADA, JANET R (ANP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:R
Last Name:CANADA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 ELLSWORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3219
Mailing Address - Country:US
Mailing Address - Phone:479-314-1101
Mailing Address - Fax:479-314-4704
Practice Address - Street 1:3501 W. E. KNIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6248
Practice Address - Country:US
Practice Address - Phone:479-709-6700
Practice Address - Fax:479-709-6768
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA02916 ANP363LF0000X
ARA02916ANP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161092758Medicaid
Q71971Medicare UPIN