Provider Demographics
NPI:1720359540
Name:PURNELL, GENTRY RENEE
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:RENEE
Last Name:PURNELL
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 1:1434 COLLINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4405 EVANS TO LOCKS ROAD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30906-7909
Practice Address - Country:US
Practice Address - Phone:706-854-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011031150225100000X
GAPT010826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist