Provider Demographics
NPI:1255713012
Name:GENTZKOW, GINA NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:GENTZKOW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:NICOLE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:704 W AVENUE C
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3456
Mailing Address - Country:US
Mailing Address - Phone:317-966-5102
Mailing Address - Fax:
Practice Address - Street 1:300 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4439
Practice Address - Country:US
Practice Address - Phone:701-323-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20352251P0200X
IN05011748A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist