Healthcare Provider Details

I. General information

NPI: 1780156679
Provider Name (Legal Business Name): DEBRA SUE GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7776 TOWNSHIP ROAD 30
DE GRAFF OH
43318-9633
US

IV. Provider business mailing address

7776 TOWNSHIP ROAD 30
DE GRAFF OH
43318-9633
US

V. Phone/Fax

Practice location:
  • Phone: 937-407-9036
  • Fax:
Mailing address:
  • Phone: 937-407-9036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN.227947
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: