Provider Demographics
NPI:1669021093
Name:GENTRY, ZACHARY BLAKE
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:BLAKE
Last Name:GENTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9338 DOSS FERRY LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:AL
Mailing Address - Zip Code:35091-2030
Mailing Address - Country:US
Mailing Address - Phone:256-620-0304
Mailing Address - Fax:
Practice Address - Street 1:307 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:HANCEVILLE
Practice Address - State:AL
Practice Address - Zip Code:35077-5476
Practice Address - Country:US
Practice Address - Phone:256-352-4767
Practice Address - Fax:256-352-4797
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-152297363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner