Provider Demographics
NPI:1316558141
Name:GILMORE, QUINTINA
Entity Type:Individual
Prefix:
First Name:QUINTINA
Middle Name:
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 1:954 S MAIN ST NE STE 130B
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-4591
Mailing Address - Country:US
Mailing Address - Phone:770-679-0364
Mailing Address - Fax:
Practice Address - Street 1:2289 JOPLIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-6775
Practice Address - Country:US
Practice Address - Phone:706-466-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP010719374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty