Healthcare Provider Details

I. General information

NPI: 1477119048
Provider Name (Legal Business Name): TERESA GENTRY APRN, C-NP, CWON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 10/21/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CANYON RD STE 3
BULLHEAD CITY AZ
86442-8624
US

IV. Provider business mailing address

2500 CANYON RD STE 3
BULLHEAD CITY AZ
86442-8624
US

V. Phone/Fax

Practice location:
  • Phone: 928-444-1454
  • Fax: 928-444-1481
Mailing address:
  • Phone: 928-444-1454
  • Fax: 928-444-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number70008
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: