Healthcare Provider Details

I. General information

NPI: 1578909255
Provider Name (Legal Business Name): ALISHA ELAINE GILMORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

IV. Provider business mailing address

PO BOX 776084 PROVIDER ENROLLMENT
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-0200
  • Fax: 479-986-3448
Mailing address:
  • Phone: 314-543-6979
  • Fax: 314-364-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number751586
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number751586
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-02192
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP123194
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02192
License Number StateNM
# 6
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number222613
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: