Provider Demographics
NPI:1760971105
Name:GENTRY, JOYCE EBOBOSERE (FNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JOYCE
Middle Name:EBOBOSERE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 FOREST SQ
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4401
Mailing Address - Country:US
Mailing Address - Phone:039-331-0162
Mailing Address - Fax:
Practice Address - Street 1:446 FOREST SQ
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4401
Practice Address - Country:US
Practice Address - Phone:903-331-0162
Practice Address - Fax:903-331-0162
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137345363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX391720501Medicaid