Provider Demographics
NPI:1639159684
Name:CANTRELL, AMMALA
Entity Type:Individual
Prefix:
First Name:AMMALA
Middle Name:
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:PO BOX 50670
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32240-0670
Mailing Address - Country:US
Mailing Address - Phone:904-673-5553
Mailing Address - Fax:904-641-1017
Practice Address - Street 1:11512 LAKE MEAD AVE UNIT 302
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9685
Practice Address - Country:US
Practice Address - Phone:904-900-3472
Practice Address - Fax:904-503-2373
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62087AOtherFLORIDA BLUE SHIELD
FLME84833OtherLICENSE NUMBER
FL62087YMedicare ID - Type Unspecified
FLH71652Medicare UPIN