Provider Demographics
NPI:1477231322
Name:GILMORE, CALLIE
Entity Type:Individual
Prefix:
First Name:CALLIE
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 1:2207 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2207 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1923
Practice Address - Country:US
Practice Address - Phone:844-493-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI246092163W00000X
WI1440633367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse