Provider Demographics
NPI:1255354114
Name:CANTRELL, HEATHER (CNM)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HANDLEY RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2178
Mailing Address - Country:US
Mailing Address - Phone:770-997-5714
Mailing Address - Fax:770-997-2810
Practice Address - Street 1:190 HANDLEY RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2178
Practice Address - Country:US
Practice Address - Phone:770-997-5714
Practice Address - Fax:770-997-2810
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144694367A00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA092104688AMedicaid