Healthcare Provider Details

I. General information

NPI: 1720359540
Provider Name (Legal Business Name): GENTRY RENEE PURNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 EVANS TO LOCKS ROAD
EVANS GA
30906-7909
US

IV. Provider business mailing address

1434 COLLINS DRIVE
MARTINEZ GA
30907
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-1598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2011031150
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: