Healthcare Provider Details

I. General information

NPI: 1043654452
Provider Name (Legal Business Name): CAROLYN S GENTRY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK DR SUITE A
HOLIDAY ISLAND AR
72631-9216
US

IV. Provider business mailing address

1 PARK DR SUITE A
HOLIDAY ISLAND AR
72631-9216
US

V. Phone/Fax

Practice location:
  • Phone: 479-253-6844
  • Fax: 479-253-6844
Mailing address:
  • Phone: 479-253-6844
  • Fax: 479-253-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR35851
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: