Provider Demographics
NPI:1821620147
Name:GILMORE, KASIDEE SHAE
Entity Type:Individual
Prefix:
First Name:KASIDEE
Middle Name:SHAE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASIDEE
Other - Middle Name:SHAE
Other - Last Name:DECOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9045 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3134
Mailing Address - Country:US
Mailing Address - Phone:801-666-6834
Mailing Address - Fax:801-904-0272
Practice Address - Street 1:9045 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3134
Practice Address - Country:US
Practice Address - Phone:801-666-6834
Practice Address - Fax:801-904-0272
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker