Provider Demographics
NPI:1629654553
Name:GILLISPIE, KATHY L (LVN)
Entity Type:Individual
Prefix:MR
First Name:KATHY
Middle Name:L
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4581
Mailing Address - Country:US
Mailing Address - Phone:817-721-5918
Mailing Address - Fax:
Practice Address - Street 1:1314 LAKE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4581
Practice Address - Country:US
Practice Address - Phone:817-721-5918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX126387164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse