Healthcare Provider Details

I. General information

NPI: 1548460397
Provider Name (Legal Business Name): ANGELLA BETH GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

IV. Provider business mailing address

800 HOSPITAL DR
COLUMBIA MO
65201-5275
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618001731
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001731
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: