Provider Demographics
NPI:1629484647
Name:GILMORE, LISA L (DNP, ACCNS, FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:GILMORE
Suffix:
Gender:F
Credentials:DNP, ACCNS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:620 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2911
Practice Address - Country:US
Practice Address - Phone:870-414-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024621364SA2200X
MO2014022682364SP0200X
MO2018035616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid