Provider Demographics
NPI:1083001960
Name:GENTILE, THERESA LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:GENTILE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1058
Mailing Address - Country:US
Mailing Address - Phone:585-967-6075
Mailing Address - Fax:
Practice Address - Street 1:50 AVENUE E
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1058
Practice Address - Country:US
Practice Address - Phone:585-967-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271273-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse