Provider Demographics
NPI:1992850929
Name:GENTRY - BREEN, ELIZABETH DIANA (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DIANA
Last Name:GENTRY - BREEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:DIANA
Other - Last Name:GENTRY - BREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4864 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6400
Mailing Address - Country:US
Mailing Address - Phone:318-330-7626
Mailing Address - Fax:318-330-7648
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7626
Practice Address - Fax:318-330-7648
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA060857367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1955710Medicaid
LA1955710Medicaid
LA5S751Medicare PIN