Provider Demographics
NPI:1861867194
Name:CANTRELL, TAMARA (RN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2096 STATE ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-7137
Mailing Address - Country:US
Mailing Address - Phone:270-556-2273
Mailing Address - Fax:
Practice Address - Street 1:2096 STATE ROUTE 1
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144-7137
Practice Address - Country:US
Practice Address - Phone:270-556-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1083329163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse