Provider Demographics
NPI:1043352685
Name:GENTRY, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 GOBLIN DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-1855
Mailing Address - Country:US
Mailing Address - Phone:870-741-8216
Mailing Address - Fax:870-741-4784
Practice Address - Street 1:720 GOBLIN DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1855
Practice Address - Country:US
Practice Address - Phone:870-741-8216
Practice Address - Fax:870-741-4784
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator