Provider Demographics
NPI:1275817918
Name:GILMORE, SHANNON LEIGH (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH
Last Name:GILMORE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1176 SANDALWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1638
Mailing Address - Country:US
Mailing Address - Phone:847-708-5853
Mailing Address - Fax:
Practice Address - Street 1:821 E GRANT HWY
Practice Address - Street 2:STE E
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3445
Practice Address - Country:US
Practice Address - Phone:847-708-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor