Provider Demographics
NPI:1053486274
Name:BENTLEY, GINA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:HOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:WATAUGA BEHAVIORAL HEALTH SERVICES
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-232-2646
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN87906163W00000X
TNAPN14084363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse