Healthcare Provider Details

I. General information

NPI: 1457077489
Provider Name (Legal Business Name): KELLIE CANTU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 ELECTRIC AVE
SPRINGDALE AR
72764-7498
US

IV. Provider business mailing address

3127 SOUTHWEST DR
JONESBORO AR
72404-8404
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-3600
  • Fax: 479-316-0372
Mailing address:
  • Phone: 870-932-3600
  • Fax: 479-316-0372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR095682
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: