Provider Demographics
NPI:1609666312
Name:GENTRY, CONNIE LOU
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LOU
Last Name:GENTRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-2164
Mailing Address - Country:US
Mailing Address - Phone:724-875-7877
Mailing Address - Fax:
Practice Address - Street 1:109 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2024
Practice Address - Country:US
Practice Address - Phone:724-875-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA85523601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health