Provider Demographics
NPI:1629354295
Name:GENTRY, STEPHANIE CAROL
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CAROL
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 1:485 W NEES AVE
Mailing Address - Street 2:APT 136
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6862
Mailing Address - Country:US
Mailing Address - Phone:559-304-4137
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-304-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022387163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse