Provider Demographics
NPI:1669985784
Name:CANTRELL, KRISTA KALYNN
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:KALYNN
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 1:30 W BRITTANY LN
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-2606
Mailing Address - Country:US
Mailing Address - Phone:972-302-2315
Mailing Address - Fax:
Practice Address - Street 1:2151 BUCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-5295
Practice Address - Country:US
Practice Address - Phone:972-302-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-11
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305995164X00000X
CAVN266824164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse