Provider Demographics
NPI:1376662171
Name:GILMORE, STEPHEN PAUL (RN)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:PAUL
Last Name:GILMORE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3010
Mailing Address - Country:US
Mailing Address - Phone:631-266-2444
Mailing Address - Fax:
Practice Address - Street 1:689 JERICO TURNPIKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-0000
Practice Address - Country:US
Practice Address - Phone:631-854-4400
Practice Address - Fax:631-854-4411
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY458758-1163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)