Provider Demographics
NPI:1629874144
Name:WEARY, GENTELLA D (CAREGIVER)
Entity type:Individual
Prefix:MRS
First Name:GENTELLA
Middle Name:D
Last Name:WEARY
Suffix:
Gender:F
Credentials:CAREGIVER
Other - Prefix:MS
Other - First Name:GENTELLA
Other - Middle Name:D
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CAREGIVER
Mailing Address - Street 1:3803 N 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1915
Mailing Address - Country:US
Mailing Address - Phone:414-210-3149
Mailing Address - Fax:414-210-3149
Practice Address - Street 1:3803 N 23RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1915
Practice Address - Country:US
Practice Address - Phone:414-210-3149
Practice Address - Fax:414-210-3149
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8726581799310400000X
WI385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care