Healthcare Provider Details

I. General information

NPI: 1720361314
Provider Name (Legal Business Name): CAMILLE ANN KANTAI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 NORTH 29TH ST, SUITE 204
NORFOLK NE
68701-0001
US

IV. Provider business mailing address

907 PINE HEIGHTS RD
WAYNE NE
68787
US

V. Phone/Fax

Practice location:
  • Phone: 402-844-8190
  • Fax:
Mailing address:
  • Phone: 402-709-4932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number63568
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number111293
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number111293
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number111293
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: