Provider Demographics
NPI:1184810665
Name:GILMORE, KIM J (CNS, NP, DNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:J
Last Name:GILMORE
Suffix:
Gender:F
Credentials:CNS, NP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PETER SEYMORE RD
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29052-9593
Mailing Address - Country:US
Mailing Address - Phone:803-360-1821
Mailing Address - Fax:803-353-3622
Practice Address - Street 1:1218 MILLER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6417
Practice Address - Country:US
Practice Address - Phone:803-497-9611
Practice Address - Fax:803-764-2003
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA932363LA2200X
SCAPMH932364SP0809X
GARN190459364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0203Medicaid
SCNP0203Medicaid