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General NPI Number Information
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NPI Number | 1699955617
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Entity Type | Organization
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Legal Business Name | AMMALA CANTRELL
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Dates
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Enumeration Date | 11/07/2007
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Last Update Date | 10/12/2012
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Provider Practice Location Address
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Address Line | 1370 13TH AVE S SUITE 216A
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-3230
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Country | US
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Telephone | 904-372-0208
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Fax | 904-853-6559
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Provider Business Mailing Address
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Address Line | PO BOX 50670
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32240-0670
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Country | US
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Telephone | 904-372-0208
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Fax | 904-853-6559
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Authorized Official
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Title or Position | PRESIDENT
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Name | AMMALA CANTRELL
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Credential | MD
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Telephone | 904-673-5553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME84833
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License Number State | FL
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