Provider Demographics
NPI:1255719316
Name:GILMER, LA-TRISHA NICHELL
Entity type:Individual
Prefix:MRS
First Name:LA-TRISHA
Middle Name:NICHELL
Last Name:GILMER
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 1:2610 ROBINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-3927
Mailing Address - Country:US
Mailing Address - Phone:989-890-5348
Mailing Address - Fax:
Practice Address - Street 1:2610 ROBINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-3927
Practice Address - Country:US
Practice Address - Phone:989-890-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-09
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0001531555Medicaid