Healthcare Provider Details

I. General information

NPI: 1952575193
Provider Name (Legal Business Name): SUSAN E GENTRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BROOKLYN JANICE RD
BROOKLYN MS
39425-9731
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-582-1188
  • Fax: 601-582-8844
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR852221
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: