Provider Demographics
NPI:1740560762
Name:GENTILE, ELLEN RUTH (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:RUTH
Last Name:GENTILE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5286
Mailing Address - Country:US
Mailing Address - Phone:318-644-2573
Mailing Address - Fax:318-644-7177
Practice Address - Street 1:3101 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5286
Practice Address - Country:US
Practice Address - Phone:318-644-2573
Practice Address - Fax:318-644-7177
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06610363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2383027Medicaid