Provider Demographics
NPI:1083843320
Name:GILMORE, LISA M (RN, MSN, MBA, CDE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GILMORE
Suffix:
Gender:F
Credentials:RN, MSN, MBA, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-444-4737
Mailing Address - Fax:860-444-4775
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-444-4737
Practice Address - Fax:860-444-4775
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT076588163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator