Provider Demographics
NPI:1760890198
Name:GENTLE, MIA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:
Last Name:GENTLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 OLD PARK ROW
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4395
Mailing Address - Country:US
Mailing Address - Phone:334-451-1146
Mailing Address - Fax:
Practice Address - Street 1:645 MCQUEEN SMITH RD N
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7268
Practice Address - Country:US
Practice Address - Phone:334-361-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-077078363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily