Provider Demographics
NPI:1518374586
Name:GENTRY, MARISA VELLA (NP-C)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:VELLA
Last Name:GENTRY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7033 SAINT ANDREWS RD STE 305
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1181
Practice Address - Country:US
Practice Address - Phone:803-936-7480
Practice Address - Fax:803-936-7481
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18959363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4359Medicaid
SCSC48457647Medicare PIN