Provider Demographics
NPI:1851064570
Name:GILMORE, FREDERICA
Entity Type:Individual
Prefix:
First Name:FREDERICA
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 1:7710 W INTERSTATE 10
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4711
Mailing Address - Country:US
Mailing Address - Phone:210-377-3355
Mailing Address - Fax:
Practice Address - Street 1:155 E SONTERRA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3989
Practice Address - Country:US
Practice Address - Phone:210-593-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX730629163W00000X
TX1046952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse