Provider Demographics
NPI:1396367868
Name:GILMORE, LARA (CRNA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 TRAFALGAR CT STE 200E
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7420
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170091163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse