Provider Demographics
NPI:1104906775
Name:GENTRY, TINA C (LPN)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:C
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CUMBERLAND ST
Mailing Address - Street 2:EXECUTIVE PLAZA 4TH FL
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201
Mailing Address - Country:US
Mailing Address - Phone:276-645-4758
Mailing Address - Fax:276-669-9093
Practice Address - Street 1:510 CUMBERLAND ST
Practice Address - Street 2:EXECUTIVE PLAZA 4TH FL
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201
Practice Address - Country:US
Practice Address - Phone:276-645-4758
Practice Address - Fax:276-669-9093
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002054425164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse