Healthcare Provider Details

I. General information

NPI: 1245868124
Provider Name (Legal Business Name): ANNA CELESTE GIBSON GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 W VAN ASCHE LOOP
FAYETTEVILLE AR
72703-4974
US

IV. Provider business mailing address

137 W VAN ASCHE LOOP
FAYETTEVILLE AR
72703-4974
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-7000
  • Fax:
Mailing address:
  • Phone: 479-751-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA199750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: