Provider Demographics
NPI:1811000516
Name:CANTRELL, JENETTE LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENETTE
Middle Name:LYNN
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VAMC BAY PINES PO BOX 5005
Mailing Address - Street 2:3A-EYE CLINIC
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV00512Medicare UPIN