Provider Demographics
NPI:1477193464
Name:GUNDRY, JUANITA (LMT)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:GUNDRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MORGAN HWY STE 4
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2641
Mailing Address - Country:US
Mailing Address - Phone:570-344-3788
Mailing Address - Fax:
Practice Address - Street 1:5 MORGAN HWY STE 4
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2641
Practice Address - Country:US
Practice Address - Phone:570-344-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012894225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist