Provider Demographics
NPI:1477235398
Name:CANTRELL, CAITLYN GRACE
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:GRACE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GASTON AVE STE 965
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3417 GASTON AVE STE 965
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2036
Practice Address - Country:US
Practice Address - Phone:972-817-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17196363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical