MEDICARE: CAROLYN S GENTRY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R35851	AR

General Provider Information

NPI Number	:	1043654452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN S GENTRY RN

Provider Business Mailing Address
First Line	:	1 PARK DR
Second Line	:	SUITE A
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-9216
Country	:	US
Telephone Number	:	479-253-6844
Fax Number	:	479-253-6844

Provider Business Practice Location Address
First Line	:	1 PARK DR
Second Line	:	SUITE A
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-9216
Country	:	US
Telephone Number	:	479-253-6844
Fax Number	:	479-253-6844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	04/29/2013

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