Healthcare Provider Details

I. General information

NPI: 1972419778
Provider Name (Legal Business Name): SHANNAH JAELIN GILMORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10275 HOLE AVE # 7243
RIVERSIDE CA
92503-3457
US

IV. Provider business mailing address

PO BOX 7243
RIVERSIDE CA
92513-7243
US

V. Phone/Fax

Practice location:
  • Phone: 714-369-4688
  • Fax:
Mailing address:
  • Phone: 714-369-4688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: