Provider Demographics
NPI:1396728416
Name:GENTRY, CARLA J (NP)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:J
Last Name:GENTRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8181 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-772-0785
Mailing Address - Fax:208-762-2704
Practice Address - Street 1:8181 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-772-0785
Practice Address - Fax:208-762-2704
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP566A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1344192OtherMEDICARE
P88670Medicare UPIN
ID1344191Medicare ID - Type Unspecified