Provider Demographics
NPI:1437678661
Name:GENTRY, AGATHA
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:
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 1:8500 RIDGEWOOD AVE APT 505
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-2148
Mailing Address - Country:US
Mailing Address - Phone:407-408-3059
Mailing Address - Fax:
Practice Address - Street 1:520 W LAKE MARY BLVD STE 214
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-7424
Practice Address - Country:US
Practice Address - Phone:800-614-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9250702163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse