Healthcare Provider Details

I. General information

NPI: 1891168829
Provider Name (Legal Business Name): REQUEL VALERIA GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E 3RD ST
CHATTANOOGA TN
37403-2102
US

IV. Provider business mailing address

631 CARRIAGE PARC DR
CHATTANOOGA TN
37421-7149
US

V. Phone/Fax

Practice location:
  • Phone: 423-209-8050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number200597
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: