Provider Demographics
NPI:1164758090
Name:GILMORE, RACHEL VERONICA (PAA)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:VERONICA
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:DEPARTMENT OF SYSTEM CREDENTIALING
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8758
Mailing Address - Fax:912-350-6509
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:DEPARTMENT OF SYSTEM CREDENTIALING
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8758
Practice Address - Fax:912-350-6509
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1964367H00000X
GA005714367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA109516991AMedicaid
GA202I326660Medicare PIN