Provider Demographics
NPI:1245614700
Name:GENTRY, KASEY LEE
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:LEE
Last Name:GENTRY
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 1:600 CHATHAM MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2482
Mailing Address - Country:US
Mailing Address - Phone:336-835-4819
Mailing Address - Fax:
Practice Address - Street 1:600 CHATHAM MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2482
Practice Address - Country:US
Practice Address - Phone:336-835-4819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC227834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily