Provider Demographics
NPI:1033159827
Name:GANTLEY, JANA RENEE (APRN)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:RENEE
Last Name:GANTLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W SUN ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1563
Mailing Address - Country:US
Mailing Address - Phone:606-207-2931
Mailing Address - Fax:606-783-0964
Practice Address - Street 1:555 W SUN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1563
Practice Address - Country:US
Practice Address - Phone:606-207-2931
Practice Address - Fax:606-783-0964
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002241363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001237Medicaid
KYP23542Medicare UPIN
KY0654705Medicare ID - Type Unspecified