Provider Demographics
NPI:1477119048
Name:GENTRY, TERESA (APRN, C-NP, CWON)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:APRN, C-NP, CWON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CANYON RD STE 3
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8624
Mailing Address - Country:US
Mailing Address - Phone:928-444-1454
Mailing Address - Fax:928-444-1481
Practice Address - Street 1:2500 CANYON RD STE 3
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8624
Practice Address - Country:US
Practice Address - Phone:928-444-1454
Practice Address - Fax:928-444-1481
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70008363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health