Provider Demographics
NPI:1376779959
Name:GILMORE, TRACEY L (IDMT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:GILMORE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3739 W HELENA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3105
Mailing Address - Country:US
Mailing Address - Phone:480-414-6513
Mailing Address - Fax:
Practice Address - Street 1:3739 W HELENA DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3105
Practice Address - Country:US
Practice Address - Phone:481-414-6513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians