Provider Demographics
NPI:1154052892
Name:CANTRELL, KHAYRASSA L (PA-S)
Entity Type:Individual
Prefix:MRS
First Name:KHAYRASSA
Middle Name:L
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5162 OLIVIA TRL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-4311
Mailing Address - Country:US
Mailing Address - Phone:678-558-8980
Mailing Address - Fax:
Practice Address - Street 1:720 WESTVIEW DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1458
Practice Address - Country:US
Practice Address - Phone:404-756-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA12060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program