Healthcare Provider Details

I. General information

NPI: 1033159827
Provider Name (Legal Business Name): JANA RENEE GANTLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W SUN ST
MOREHEAD KY
40351-1563
US

IV. Provider business mailing address

555 W SUN ST
MOREHEAD KY
40351-1563
US

V. Phone/Fax

Practice location:
  • Phone: 606-207-2931
  • Fax: 606-783-0964
Mailing address:
  • Phone: 606-207-2931
  • Fax: 606-783-0964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number3002241
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: