Healthcare Provider Details

I. General information

NPI: 1134983687
Provider Name (Legal Business Name): JUSTIN CANTRELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 MAGNOLIA POINT CIR
PEARL MS
39208-1207
US

IV. Provider business mailing address

764 MAGNOLIA POINT CIRCLE
PEARL MS
39208
US

V. Phone/Fax

Practice location:
  • Phone: 985-789-3504
  • Fax:
Mailing address:
  • Phone: 985-789-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberT-5854
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: