Provider Demographics
NPI:1962239889
Name:CANTRELL, CHARLES CHRISTIAN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHRISTIAN
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 QUENTIN DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-3733
Mailing Address - Country:US
Mailing Address - Phone:210-887-1138
Mailing Address - Fax:
Practice Address - Street 1:9939 TEXAS 151 ACCESS RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-887-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685541163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator