Basic Information
| Provider Information | |||||||||
| NPI: | 1851573349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAY CANTRELL | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 SHELBYVILLE RD STE 220 | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 5024296157 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 POPLAR AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381194810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017576100 | ||||||||
| FaxNumber: | 8556567329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1562 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.