Provider Demographics
NPI:1629167341
Name:GALLMORE, LISA JOY (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOY
Last Name:GALLMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7128
Mailing Address - Country:US
Mailing Address - Phone:734-728-2130
Mailing Address - Fax:734-728-2626
Practice Address - Street 1:6149 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7128
Practice Address - Country:US
Practice Address - Phone:734-728-2130
Practice Address - Fax:734-728-2626
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4766340Medicaid