MEDICARE: LISA L. GILMORE DNP, ACCNS, FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0200X	Pediatric Clinical Nurse Specialist	2014022682	MO
2	364SA2200X	Adult Health Clinical Nurse Specialist	2014024621	MO
3	363LF0000X	Family Nurse Practitioner	2018035616	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629484647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA L. GILMORE DNP, ACCNS, FNP

Provider Business Mailing Address
First Line	:	PO BOX 7411626
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-5626
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 N MAIN ST
Second Line	:
City	:	HARRISON
State	:	AR
Zip	:	72601-2911
Country	:	US
Telephone Number	:	870-414-4076
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2014
Last Update Date	:	03/13/2026

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