Healthcare Provider Details

I. General information

NPI: 1124094529
Provider Name (Legal Business Name): LORETTA M GILMORE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORETTA M GAITHER

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 WALLACE ALLEY ST
KINGSPORT TN
37663-3936
US

IV. Provider business mailing address

PO BOX 3549
CHATTANOOGA TN
37404-0549
US

V. Phone/Fax

Practice location:
  • Phone: 423-390-0451
  • Fax:
Mailing address:
  • Phone: 423-698-3309
  • Fax: 423-624-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN135808
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN114674
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN10167
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: