Provider Demographics
NPI:1225222946
Name:GILLMORE, MICHELLE M (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:GILLMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:HAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-7490
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:1201 E MICHIGAN AVE STE 240
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1855
Practice Address - Country:US
Practice Address - Phone:517-205-1591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211845363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704211845OtherSTATE LICENSE