Provider Demographics
NPI:1144517038
Name:TOLBERT, GENTRY BROACH (NP)
Entity type:Individual
Prefix:
First Name:GENTRY
Middle Name:BROACH
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LANGFORD MEDICAL DRIVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622
Mailing Address - Country:US
Mailing Address - Phone:706-208-0451
Mailing Address - Fax:
Practice Address - Street 1:1000 HAWTHORNE AVE STE J
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2168
Practice Address - Country:US
Practice Address - Phone:706-286-8344
Practice Address - Fax:706-286-8346
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175489363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily