Provider Demographics
NPI:1972903441
Name:GORE, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6202
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX729857163W00000X, 163WA2000X, 163WM0705X, 163WP0200X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX729857OtherTEXAS BOARD OF NURSING