Healthcare Provider Details

I. General information

NPI: 1285754259
Provider Name (Legal Business Name): LISA GILMORE CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 BROADWAY
NEW YORK NY
10032-1559
US

IV. Provider business mailing address

1785 215TH ST APT 17A
BAYSIDE NY
11360-1727
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-8458
  • Fax:
Mailing address:
  • Phone: 718-428-4182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberF380564
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: