Healthcare Provider Details

I. General information

NPI: 1912223389
Provider Name (Legal Business Name): MICHELE ANITA CANTRELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2010
Last Update Date: 11/18/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 TROUSDALE DR 5TH FLOOR
BURLINGAME CA
94010-4506
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8787
  • Fax:
Mailing address:
  • Phone: 650-652-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200440425RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number567223
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: