Provider Demographics
NPI:1831762442
Name:GENTRY, VIRGINIA POOLE
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:POOLE
Last Name:GENTRY
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 1:1190 N STATE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2463
Mailing Address - Country:US
Mailing Address - Phone:601-968-0896
Mailing Address - Fax:
Practice Address - Street 1:1190 N STATE ST STE 202
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2463
Practice Address - Country:US
Practice Address - Phone:601-968-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily