Provider Demographics
NPI:1417072422
Name:GILLMORE, MICHAEL (RNFA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GILLMORE
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3614
Mailing Address - Country:US
Mailing Address - Phone:217-343-8721
Mailing Address - Fax:
Practice Address - Street 1:100 DEERPATH
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-9427
Practice Address - Country:US
Practice Address - Phone:217-345-2727
Practice Address - Fax:217-345-2781
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical