Provider Demographics
NPI:1588188619
Name:GENTRY, MANDY KAY (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MANDY KAY
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:MANDY KAY
Other - Middle Name:
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:660 S MOUNT JULIET RD STE 130
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6496
Mailing Address - Country:US
Mailing Address - Phone:865-588-3173
Mailing Address - Fax:
Practice Address - Street 1:660 S MOUNT JULIET RD STE 130
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6496
Practice Address - Country:US
Practice Address - Phone:865-588-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23090363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032672Medicaid
MS08976882Medicaid