Provider Demographics
NPI:1538823299
Name:CANTRELL, DOROTHY SHAWN (PA)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:SHAWN
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:10050 SW INNOVATION WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2117
Mailing Address - Country:US
Mailing Address - Phone:772-344-3811
Mailing Address - Fax:772-335-2422
Practice Address - Street 1:10080 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2127
Practice Address - Country:US
Practice Address - Phone:772-285-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
FL9115906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant