Healthcare Provider Details

I. General information

NPI: 1427474931
Provider Name (Legal Business Name): MARY GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 5TH ST NE
ALICEVILLE AL
35442-2200
US

IV. Provider business mailing address

100 5TH ST NE
ALICEVILLE AL
35442-2200
US

V. Phone/Fax

Practice location:
  • Phone: 205-373-1574
  • Fax:
Mailing address:
  • Phone: 205-373-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-109137
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: