Individual
AMMALA CANTRELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
11512 LAKE MEAD AVE UNIT 302, JACKSONVILLE, FL 32256-9685
(904) 900-3472
(904) 503-2373
Mailing address
PO BOX 50670, JACKSONVILLE BEACH, FL 32240-0670
(904) 673-5553
(904) 641-1017
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
ME84833
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
62087A
FLORIDA BLUE SHIELD
FL
01
—
ME84833
LICENSE NUMBER
FL
Enumeration date
01/18/2006
Last updated
04/09/2018
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