Healthcare Provider Details

I. General information

NPI: 1396353397
Provider Name (Legal Business Name): JOHN GILMORE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

2395 LAKE SHORE DR S
GOREVILLE IL
62939-3167
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 224-316-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021629
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: