MEDICARE: MS. MARY MELISSA CANTRELL APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	A03407	AR

General Provider Information

NPI Number	:	1043523228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY MELISSA CANTRELL APN

Provider Business Mailing Address
First Line	:	105 NATHAN ST
Second Line	:
City	:	MARKED TREE
State	:	AR
Zip	:	72365-1447
Country	:	US
Telephone Number	:	870-358-2036
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 NATHAN ST
Second Line	:
City	:	MARKED TREE
State	:	AR
Zip	:	72365-1447
Country	:	US
Telephone Number	:	870-358-2036
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	12/01/2011

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