Provider Demographics
NPI:1588302392
Name:CANTRELL, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 RED BUG LK. RD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708
Mailing Address - Country:US
Mailing Address - Phone:407-359-1717
Mailing Address - Fax:
Practice Address - Street 1:1675 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8928
Practice Address - Country:US
Practice Address - Phone:407-359-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59148207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine