Healthcare Provider Details

I. General information

NPI: 1811813603
Provider Name (Legal Business Name): TINA CANTRELL PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8180 REGENT PKWY STE 109
FORT MILL SC
29715-8417
US

IV. Provider business mailing address

317 BLUE SKY DR NW
CONCORD NC
28027-7344
US

V. Phone/Fax

Practice location:
  • Phone: 803-979-6171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5024728
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: