Provider Demographics
NPI:1508638057
Name:COTTRELL-PRATT, CHANAE
Entity Type:Individual
Prefix:
First Name:CHANAE
Middle Name:
Last Name:COTTRELL-PRATT
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 1:10014 WHITE BLUFF RD APT 1503
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-5605
Mailing Address - Country:US
Mailing Address - Phone:801-616-8236
Mailing Address - Fax:
Practice Address - Street 1:10080 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2127
Practice Address - Country:US
Practice Address - Phone:772-344-3811
Practice Address - Fax:772-344-3890
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9117794363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant