Healthcare Provider Details

I. General information

NPI: 1770446809
Provider Name (Legal Business Name): NACISKA SHANTEL GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N CLEAR SPRINGS RD
MUSTANG OK
73064-1502
US

IV. Provider business mailing address

4804 KRISTIE DR APT 89
DEL CITY OK
73115-4838
US

V. Phone/Fax

Practice location:
  • Phone: 405-376-7322
  • Fax:
Mailing address:
  • Phone: 405-265-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: