Healthcare Provider Details

I. General information

NPI: 1003751686
Provider Name (Legal Business Name): DIANNA MICHELLE CANTRELL RBA, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

V. Phone/Fax

Practice location:
  • Phone: 304-436-2107
  • Fax: 304-436-6362
Mailing address:
  • Phone: 304-436-2107
  • Fax: 304-436-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: