Provider Demographics
NPI:1740684554
Name:OBRY, GENA
Entity type:Individual
Prefix:
First Name:GENA
Middle Name:
Last Name:OBRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 AVENUE D SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3531
Mailing Address - Country:US
Mailing Address - Phone:863-229-5414
Mailing Address - Fax:
Practice Address - Street 1:439 AVENUE D SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3531
Practice Address - Country:US
Practice Address - Phone:863-229-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906588311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012306000Medicaid