Provider Demographics
NPI:1043812910
Name:GILMORE, CHARELL A
Entity Type:Individual
Prefix:
First Name:CHARELL
Middle Name:A
Last Name:GILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23670 BANBURY CIR APT 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5359
Mailing Address - Country:US
Mailing Address - Phone:216-312-8333
Mailing Address - Fax:
Practice Address - Street 1:23670 BANBURY CIR APT 3
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5359
Practice Address - Country:US
Practice Address - Phone:216-312-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400199000103374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide