Provider Demographics
NPI:1679157994
Name:CANTRELL, TARA D
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:D
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 1:1333 W GUADALUPE RD APT 1211
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3023
Mailing Address - Country:US
Mailing Address - Phone:480-299-7280
Mailing Address - Fax:
Practice Address - Street 1:1333 W GUADALUPE RD APT 1211
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3023
Practice Address - Country:US
Practice Address - Phone:480-299-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)