Provider Demographics
NPI:1194779363
Name:GENTRY, SUE AVERY (CRNA)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:AVERY
Last Name:GENTRY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HILLCREST PKWY STE L
Mailing Address - Street 2:PMB 214
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3581
Mailing Address - Country:US
Mailing Address - Phone:478-274-8671
Mailing Address - Fax:
Practice Address - Street 1:2400 BELLEVUE RD STE 22
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2889
Practice Address - Country:US
Practice Address - Phone:478-275-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN055565367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCCDC02Medicare PIN
GAS49837Medicare UPIN