Provider Demographics
NPI:1699171561
Name:CANTRELL KELLEY, JOANNA MICHELLE (BSE, MED)
Entity type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:MICHELLE
Last Name:CANTRELL KELLEY
Suffix:
Gender:F
Credentials:BSE, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 LINDLEY LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-4954
Mailing Address - Country:US
Mailing Address - Phone:479-523-2124
Mailing Address - Fax:870-523-5168
Practice Address - Street 1:221 LINDLEY LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-4954
Practice Address - Country:US
Practice Address - Phone:479-523-2124
Practice Address - Fax:870-523-5168
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist