Provider Demographics
NPI:1609199967
Name:GENTRY, NICOLE MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 RIVERSIDE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5453
Mailing Address - Country:US
Mailing Address - Phone:136-848-1934
Mailing Address - Fax:
Practice Address - Street 1:2114 RIVERSIDE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5453
Practice Address - Country:US
Practice Address - Phone:136-848-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019293174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist