Basic Information
Provider Information | |||||||||
NPI: | 1538541768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CANTRELL | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | LONGO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LONGO | ||||||||
OtherFirstName: | KATIE | ||||||||
OtherMiddleName: | KIMBERLY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 746638 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303746638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042021032 | ||||||||
FaxNumber: | 9043764107 | ||||||||
Practice Location | |||||||||
Address1: | 520 A1A N STE 101 | ||||||||
Address2: |   | ||||||||
City: | PONTE VEDRA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 320822260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042736900 | ||||||||
FaxNumber: | 9043907479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2015 | ||||||||
LastUpdateDate: | 08/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125-066188 | IL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | ME136447 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.